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HomeMy WebLinkAbout2010 MECHANICAL PERMITS A-M - ALPINE ST - PERMvr' ,A_E tar Map #: Lot #: Untt#: Street #: Street Name: Street t11l0 71` : Perirri*#: 3\1 Department.: Document Type: Buitritenz (Plazi) CPI tt TOWN OF LEXINGTON Community Development Building Division o� =' 7 3 ttts "c The Commonwealth of Massachusetts > State Board of Regulations and Standards Massachusetts' V a State Building Code For One- and Two- Family Dwellings pppl9 " 7th Edition APPLICATION FOR: ROOFING, SIDING, WINDOWS, DOORS Mailing Address: 1 Countryside Village Lexington, MA 02420 SITE INFORMATION: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Permit # /C/ -/3 /-bate issued: / Work approved by: Expiration Date 12/18/2011 Property Address: 3 0,...tip ', 0 4. b\-- Historic District: Yes/ No Registered Home Improvement Contractor: Company Name: Assessors Map /Parcel # ,S 9 2 8 Provide name of Waste /Rubbish hauler All State Waste Address: 67 Perkins Ave. Brockton, MA 02302 Is this hauler currently permitted through the Health Department? Yes Phone # 1- 888 -559 -0909 Roofing 5900: (Note: Roofing is not permitted over more than one (1) existing layer. If two layers of roofing exist, then roof must be stripped before re- roofing.) Roofing shall be installed according to manufacturing recommendations. Proposed work: Strip and re -roof Re -roof over existing single course Number of squares Location on roof Does this involve replacement of sheathing? Yes/No Number of existing layers of roofing? Siding 5700: (Note: Electrical Permit required with application) Proposed work: Strip & re -side Re -side over existing Existing material: Proposed material: Electrical Permit: Yes/No Door Replacement: (Note: Maximum U .44) Number of replacement doors: 2 Estimated cost of work and material excluding electrical cost: /y0� PROPERTY OWNERSHIP /AUTHORIZED AGENT: Owner of Record: Name (printed) Lexington Housing Authority Mailing Address: 1 Countryside Village Lexington, MA 02420 Signature Phone # 781 - 861 -0900 Authorized Agent: Name (print d): Signature: h. Phone # 781 - 861 -0900 Mailing Address: 1 Countryside Village Lexington, MA 02420 CONSTRUCTION SER ICES: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Not Applicable: License Number 76563 Expiration Date 12/18/2011 Address: 86 Bedford St. Lakeville MA 02347 Signature: )k" "t et,,,,` Phone # 508 - 583 -3999 Registered Home Improvement Contractor: Company Name: Not Applicable X Registration Number Expiration Date Address: Si anal-tire! Phone # Received by /date: DYV 141 )11 Fee: Receipt #: Issued By: /a/ve- Map #: Lot #: Unit*: Street #: Street Name:;rv. Street Untt #: Permit*: Departs t; �uatd n� Document 'h`y'pe :_adi ) CP14t) - (F •••■••..... L\ M mss' /i/c-e)t7/9 TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax 781- 861 -2780 Date: l I c)t/tt? Type of Oc pa cy: _ Permit ye_ Building Location: Owner's Name: ti A4� ` �i 40 IA Installing Company Name: r h Company Slc et A r,e:4� 4,/j441.,7 To� ' / iZip. Indicate total number of units in the applicable box below Describe type of work and location. *If any equipment is being placed outside of the footprint of the building, describe location and indicate setbacks to property f.e. -land survey may be requited. Roof . units may require a Str ural Engineer's review: eto- New Work ❑ ReplacementI Renovation ❑ Plans Submitted: ❑ I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the ICC M-chanical Code, and all laws/bylaws /rations of the Town of Lexington: titr Print Nam Si. ature: (1t 64Ej:; Type of License: License #: Basement 1st 2nd 3rd w 00 cc Ground* Air Handling Units Date issued: 70//7//0 Heating Zones Evaporative Coolers Heat Pumps Range Hoods - aeration Units Conn, Sprinkler Heads Sprin., - Hose Conn. t10, . : - . urnac -'s /Gas/ `rocess Piping Direct Vent Fireplace Generators Roof Top Units No Vent Heaters Central Air Conditioners Steam Kettles Duct Coils Describe type of work and location. *If any equipment is being placed outside of the footprint of the building, describe location and indicate setbacks to property f.e. -land survey may be requited. Roof . units may require a Str ural Engineer's review: eto- New Work ❑ ReplacementI Renovation ❑ Plans Submitted: ❑ I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the ICC M-chanical Code, and all laws/bylaws /rations of the Town of Lexington: titr Print Nam Si. ature: (1t 64Ej:; Type of License: License #: Basement Est 2nd 3rd Roof 1 Ground* Fire Suppression Date issued: 70//7//0 Draft Inducers Kitchen Equipment Pool Heater Pumps Radiant Heat Incinerators Steam Generators Baseboard Heat Radiators Kickspace Heaters Hydro Air Systems Direct Vent Fireplace Roof Top Units Central Air Conditioners Describe type of work and location. *If any equipment is being placed outside of the footprint of the building, describe location and indicate setbacks to property f.e. -land survey may be requited. Roof . units may require a Str ural Engineer's review: eto- New Work ❑ ReplacementI Renovation ❑ Plans Submitted: ❑ I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the ICC M-chanical Code, and all laws/bylaws /rations of the Town of Lexington: titr Print Nam Si. ature: (1t 64Ej:; Type of License: License #: For Office Use Only lnsuran - o File- Will Fax: P et Fie: $ Receipt# 9,e 6 Date issued: 70//7//0 /3/44s3 TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PE T 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit. FEE: $12 per one thousand valuation or any portion thereof Property Address: (© yvc, ( ,.5L, ,, 2 Owner of Record: Go_ U. Assessors Map # l`U Lot # 3,7 - ,33 Type of Occupancy: New: Renovation: Replacement: X Plans Submitted: Yes No Installing Company Name: CC vv- }-ra„\ Cool ;h) Company Street Address: y ,!'l, ,14c 7,k Si-, City: W64Urt7 Zip: c /,PO,, Company Phone Number: -7t /— Estimated Cost: $ Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement aoold as l, 2nd Floor °o u._ M o cc c 2 Ur Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: I Basic Building Code Commercial Basement S u_ o L N o L M Roof c 0 U Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may besequired. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: /� \.N Q CrS'�, 6`P:� 1 r'A e:S n �" Y � f' � �% r t �'► �1 7L2, 4. C`n -, I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the assac se tate Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of ingt Lt, gQr-,e CILS Crn-► i Print Name: Permit ee: Issued B Type of License: This Section for Offical Use OnI Receipt #: ?J33Z) Revised 12/31/09 Date Received: Q License #: Received by: Approved Date: 9(4940 Permit Number: /e fO 96 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 x}ww.mass.gor /dia Workers Compensation.. Insurance Affidavit: Builders /Contractors /Electricians /Plumbers Applicant Information y Please Print l.,egibl� Name ( Business /OrgaYUzatiort1ndividuaf : , 1 +.! % t, iii -r' s i' �•,� ( {. ,, fr; Address :_ ..� Y c C_ 1 e�i_ f - ' i tip •` f �'" �. � tr t Map # L Address: Permit .,iv /Siaie /Zip: LA), },. b i ionesir. Are you an employer? Check the appropriate box: 1. El I am a employer with � 4. ❑ I am a general contractor and 1 employees (full and/or part-time).* have hired the sub - contractors 2. I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.) 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.I 5. 0 We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. 0 New construction 7. 0 Remodeling 8. (] Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 1312 Other kfirk2?e.. *My applicant that checks box it 1 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 =Contractors that check this box must attached an additional sheet showing the naive of the subcontractors and state whether ornot those entities have employees. If the sub - contractors have eniployees, they must provide their workers' comp. policy number. Pam an employer that is providing workers' compensation insurance for my employees Below is' the policy and job site information. Insurance Company Name: 6- (_a 13 t } L, LEW 5-u, R. F%N CC /.I ?`-(.,,J K 3 Policy # or Self -ins. Lic. #: ,} (} 06 C7 t 3 6 Expiration Date: 1 1 1 a v-e+ 11,11:17 Cone Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). .lob Site Address: City /State /Zip: L 1�1) /11 Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the in ositionn of criminal penalties of a fine up to $1,500.00 and /or one -year iimprisonnaent, 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 Investi adorns of the DIA. for insurance covers e verification. 1 -deg he Signs r the pains and penalties of perjury that the information provided above is ;rue and correct Date: 9 %1d %/0 P'o,e #; iGI - '' - Fp v` 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation far their employees. Pursuant to this Statute, an employee is defined as "...every person ill the service o12 ailothC.r under any contract oflircy e „pl ess o; implied, oral at vritteri. An employer is defined as "an.individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver- or trustee of an individual, parnier ship, association or other legal entity, employing employees. 'However the owner of a dwelling house having not more than thee, apaitn ents and who resides therein, or the occupant of the (IN: Yelling house of another who employs persons to do Inainteuan:e. CanstuCtiori or repair work on such dwelling house or on the pounds or building appwten ?-lit thereto shall, not because- of such esnnlnyri ern be deemed to he an employer,' MGL chapter 152, §25C(6) also states that "every state ur 1ocat licensing agency shalt 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, §25C(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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(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 confnmation 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 thew self-insurance license number on the • = to =rate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space et 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 cure, to fill in the permit/license number which will be used as a reference. number, In addition; an applicant that "rust submit rmltiple permit/license applications in any givers year, need only submit one affidavit indicating current policy inforrnation (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 "rust be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.. a dog license oI permit to burn 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 as 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 Revised 11-22-06 Tel. # 617- 727 -4900 ext 406 or 1- $77- MASSAFE Fax # 617- 727 -7749 vvww.nass.gov /dia tar-- ./Y-teg4 \YAk-d_ Map #: Lot #: Unit #: Street#: 'treet Name: =reet Unnt #: 0 f2 /L ■■■■■_iO /13.3 emorrepoxamw Department: B u iltiing i)cciument Tvpe: Ew.,2_ lFlot) (Perm TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 19 7pri / /a'- Owner of Record: _ j a 4; Li Assessors Map # ,/D Lot # ..3 Type of Occupancy: '�sJQQ11 T/a, C New: Renovation: Replacement: ZPlans Submitted: Yes No Installing Company Name: M , E o�'o `Z , :Tn C Company Street Address: 1(0579 441,644,5,-City: (4)0,i v,r4 %4 Zip: a<PO / Company Phone Number: _721-1.13:-_79.„ Estimated Cost: 16'700.0 Indicate total number of units in the applicable box below Basic Building Code Commercial 1&2 Family Basement 1St Floor 2nd Floor 3rd Floor 0 rt Ground* Air Handling Units I f Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps I Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Fumaces- Oil Generators Other: Basic Building Code Commercial Basement 1st Floor 2nd Floor 3rd Floor Roof c ' 0 6 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws/regulations of the Town of L Signature: not Name: Type o se: License #: This Section for Offical Use Only Permit fee: \D% Rece t %<J Issued By Revised 12/31/09 �'"�• Date Received: bet' f °7) Approved Dat ei j/� / /,o, Received by: Permit Number: �o _ %l-J3 di.-6J 7itte-t- 7>tezd__ i Map #: Lot #: � G Unit #: Street##: 'treet Name: ,15;1((/ Meet Unit #: 3ermit #: Department: 7-16 Bi��ldta' Doeltrnent Type: ap (Fear) TOWN OF LEXINGTON Permit Number APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781-862-0500 x -211 Fax: 781 -861 -2780 Building Loc t n: 46 Asbury Rd. Owner's Name: Richard Zapolin Map #3 Lot# l0 -- 76F6 Type of Occupancy: RESIDENCE New: Renovation:ia Replacement: Plans Submitted: Yes No xx Installing Company Name: FEDERAL HEATING & ENGINEERING Company Street Address: 1 60 CROSS ST City: WINCHESTER Zip: 01890 Company Phone Number: 781-721-2468 Indicate total number of units in the applicable box below M Basement °o 2nd Floor 8 Cr_ a o 'c U Air Handling Units Draft Inducers Heating Zones Kitchen Equipment Evaporative Coolers Pool Heater Heat Pumps Pumps Range Hoods Radiant Heat Refrigeration Units Radiant Heat Sprinkler Connection Steam Generators Sprinkler Heads Baseboard Heat Sprinkler Hose Conn. Radiators Ventilation Fans Kick -space Heaters Boilers -Gas Hydro Air Systems Boilers -Oil Direct Vent Fireplace Furnaces -Gas -7 Central Air Conditioners Furnaces -Oil Process Piping Generators No Vent Heaters Steam Kettles Duct Coils Describe Project: `Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A and survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington'Noise By -Law: Basement o — o o II N Floor Roof* " = 2 0 Fire Suppression Draft Inducers Kitchen Equipment Pool Heater Pumps Radiant Heat Radiant Heat Incinerators Steam Generators Baseboard Heat Radiators Kick -space Heaters Hydro Air Systems Direct Vent Fireplace Roof Top Units -7 Central Air Conditioners Describe Project: `Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A and survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington'Noise By -Law: I certify that 1 have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for thi plication will be in compliance with all pertinent provisions of the Massachusetts State Baling Code, the ICC Me nical Code, an III /b laws /regulations of the Town of Lexington: %...,, �V6 TOM T,APOTNTF UNIVFRSPT4 0001 64579 Signature. :. Printed name: Type of License License # Permit fee: 9 Receipt #:°7 This Section for Official Use Only Date Received:1444 Inspector: Received by: Approved Date: Rev 5/12/09 Map #: Lot*: Unit #: Street #: n Street Name: ` c\`5. Street U,z1Et#:.�r _ Permit*: \ O 3 \ \ y Department: Buitt in1 (131 Document TyPc: �t TOWN OF LEXINGTON Community Development Building Division •p`� a a : r. 1. ; `App'~ us Mo tT , The Commonwealth of Massachusetts State Board of Regulations and Standards Massachusetts W State Building Code For One- and Two- Family' Dwellings 7th Edition APPLICATION FOR: ROOFING, SIDING, WINDOWS, D OORS Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika SITE INFORMATION: Not Applicable: License Number 76563 • Permit # /D -kV/ Date issued: /1/17/ Work approved by: Signature: AS-- ow. Phone # 508 -583 -3999 Property Address: \' ash S-fr. Address: Historic District: Yes,' No Signature: Phone # Assessors Map /Parcel # 1 g, 3 Provide name of Waste /Rubbish hauler All State Waste Address: 67 Perkins Ave. Brockton, MA 02302 Is this hauler currently permitted through the Health Department? Yes Phone # 1- 888 -559 -0909 Roofing 5900: (Note: Roofing is not permitted over more than one (1) existing layer. If two layers of roofing exist, then roof ' must be stripped before re- roofing.) Roofmg shall be installed according to manufacturing recommendations. Proposed work: Strip and re -roof Re -roof over existing single course Number of squares Location on roof Does this involve replacement of sheathing? Yes/No Number of existing layers of roofing? Siding 5700: (Note: Electrical Permit required with application) Proposed work: Strip & re -side Re -side over existing Existing material: Proposed material: Electrical Permit: Yes/No Door Replacement: (Note: Maximum U .44) Number of replacement doors: 2 Estimated cost of work and material excluding electrical cost: PROPERTY OWNERSHIP /AUTHORIZED AGENT: Owner of Record: Name (printed) Lexington Housing Authority Mailing Address: 1 Countryside Village Lexington, MA 02420 Signature Phone # 781 - 861 -0900 Authorized Agent: Name (print d): Signature: hi . Phone # 781 - 861 -0900 Mailing Address: 1 Countryside Village Lexington, MA 02420 CONSTRUCTION SE VICES: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Not Applicable: License Number 76563 Expiration Date 12/18/2011 Address: 86 Bedford St. Lakeville MA 02347 Signature: AS-- ow. Phone # 508 -583 -3999 Registered Home Improvement Contractor: Company Name: Not Applicable X Registration Number Address: Expiration Date Signature: Phone # Received b /date: ori./ 91 /7/ / 0 Fee: 3 Receipt #: 111 Issued By: #8„011.,..tuf JilA 1-4e4 7/te,t- Map #: J 0 Lot #: Unit #: Street##: ' 9treet Name: 114/ P&90VV Treet Unit #: 'ttrtnit #: /D -00 Oepartment: Building U)oeur ent Type: _ PLE: ) Ot IFI (Pern21 TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 -862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work aithorized is NOT done in conjunction with a BuildingPermit FEE: $12 per one thousand valuation or any portion thereof Property Address: , AZ, 4, --7 Owner of Record: Assessors Map # Lot # 7 Type of Occupancy: Xif, Replacement: Plans Submitted: Yes No /5/A/' - 1(4 / /; % / City: / Ste' Zip: g/g2/ New: Renovation: Installing Company Name:. Company Street Address: Company Phone Number: fly' x'`5'5 -` --ago'/ Estimated Cost: $ 1 Indicate total number of units in the applicable box below Family 'VI 1 &2 Basement 1 �' Floor 2nd Floor _o u. Roof '''2n 4 Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement 1 8 LL. $. u- of u- co - 8 /roffn V Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pooh Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: / / / ,t 1-e ,rS<rf R !!ib�JG�9C /ice M / ��+ f.'or�+Y I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and ail laws/bylaws /regulations of the Town of Lexington: gnature: ww Print Name: / Type of License License #: This Section for Offical Use my Permit fee: 30.00 Receipt #: 9-66 61 Date Received: 3/31/ Issued By: — roved Date: 70/-D Revised 12/31/09 5/6((D Received by: ,IC Permit Number: 10 /-/A //Z(_,;,/ Map #: Lai#: Unit #: Street #: Street Name: Street Uriti #: Perm#: Depatt at: • Buitcliaz . Document Type: CP1Ckt) 3 TOWN OF LEXINGTON Community Development Building Division u5 MOq N .�`o ,DTs ~c" <T z- ; 1=a _` a ._ �,� , �fIN ZJ The Commonwealth of Massachusetts State Board of Regulations and Standards Massachusetts State Building Code For One- and Two - Family Dwellings /`h Edition APPLICATION FOR: ROOFING, SIDING, WINDOWS, DOORS SITE INFORMATION: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Permit #/1 -/3/1 Date issued:_ Work approved by: Property Address: t 0 (your 3 T.P Q-X Address: 86 Bedford St. Lakeville, MA 02347 Historic District: Yes/ No Assessors Map /Parcel # rf a, y pia_ ft- ,,Q,) Registered Home Improvement Contractor: Company Name: Provide name of Waste /Rubbish hauler All State Waste Address: 67 Perkins Ave. Brockton, MA 02302 Is this hauler currently permitted through the Health Department? Yes Phone # 1- 888 -559 -0909 Roofing 5900: (Note: Roofing is not permitted over more than one (1) existing layer. If two layers of roofing exist, then roof must be stripped before re- roofing.) Roofing shall be installed according to manufacturing recommendations. Proposed work: Strip and re -roof Re -roof over existing single course Number of squares Location on roof Does this involve replacement of sheathing? Yes/No Number of existing layers of roofing? Siding 5700: (Note: Electrical Permit required with application) Proposed work: Strip & re -side Re -side over existing Existing material: Proposed material: Electrical Permit: Yes/No oor Replacement: e: Maximum U .44) Number of replacement doors: 2 Estimated cost of work and material excluding electrical cost: $% 1100 PROPERTY OWNERSHIP /AUTHORIZED AGENT: Owner of Record: Name (printed) Lexington Housing Authority Mailing Address: 1 Countryside Village Lexington, MA 02420 Signature Phone # 781 - 861 -0900 Authorized Agent: Name (print): Signature: Phone # 781 -861 -0900 Mailing Address: 1 Countryside Village Lexington, MA 02420 CONSTRUCTION SE VICES: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Not Applicable: License Number 76563 Expiration Date 12/18/2011 Address: 86 Bedford St. Lakeville, MA 02347 Signature: I),j_ - Phone # 508 -583 -3999 ,,Q,) Registered Home Improvement Contractor: Company Name: Not Applicable X Registration Number Address: Expiration Date Signature: Phone # Received by /date: (Y17 )101)6 Fee: Receipt #: Issued By: .8 ,//td ta,a/-4 Map*: Lot*: Unit #: Street*: Street Name: Street li,ritt-#: z 5 Perim**: _ (3a0 Department: Butkiinz Document Ty pc: ' :t (PI TOWN OF LEXINGTON Community Development Building Division b 0 a ''T �ex�ry s MOAN'/ '»s avan i � ,zoP % _` The Commonwealth of Massachusetts State Board of Regulations and Standards Massachusetts' State Building Code For One- and Two - Family Dwellings 7th Edition APPLICATION FOR: ROOFING, SIDING, WINDOWS, DOORS SITE INFORMATION: Not Applicable: License Number 76563 Permit # ,/ date issued:���) Work approved by: Property Address: (.VOr E2 Signature: a,,,; Phone # 508- 583 -3999 Registered Home Improvement Contractor: Company Name: Historic District: Yes/ No Assessors Map /Parcel # 7 9' 5-,,,Z Signature: Phone # Provide name of Waste /Rubbish hauler All State Waste Address: 67 Perkins Ave. Brockton, MA 02302 Is this hauler currently permitted through the Health Department? Phone # 1- 888 -559 -0909 Yes Roofing 5900: (Note: Roofing is not permitted over more than one (1) existing layer. If two layers of roofing exist, then roof must be stripped before re- roofing.) Roofmg shall be installed according to manufacturing recommendations. Proposed work: Strip and re -roof Re -roof over existing single course Number of squares Location on roof Does this involve replacement of sheathing? Yes/No Number of existing layers of roofing? Siding 5700: (Note: Electrical Permit required with application) Proposed work: Strip & re -side Re -side over existing Proposed material: Existing material: Electrical Permit: Yes/No Door Replacement: (Note: Maximum U .44) Number of replacement doors: 2 Estimated cost of work and material excluding electrical cost: PROPERTY OWNERSHIP /AUTHORIZED AGENT: Owner of Record: Name (printed) Lexington Housing Authority Mailing Address: 1 Countryside Village Lexington, MA 02420 Signature Phone # 781 - 861 -0900 Authorized Agent: Name (printpd): Signature: Phone # 781 - 861 -0900 Mailing Address: 1 Countryside Village Lexington, MA 02420 CONSTRUCTION SE ICES: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Not Applicable: License Number 76563 Expiration Date 12/18/2011 Address: 86 Bedford St. akeville, MA 02347 Signature: a,,,; Phone # 508- 583 -3999 Registered Home Improvement Contractor: Company Name: Not Applicable X Registration Number Address: Expiration Date Signature: Phone # Received by /date: c v t(k7) 2> Fee: 3D Receipt #: Issued By: JixY) d-e-e-4 Map #:_ Lot #: Unit #: Street #: Street Name: j./z-Z- rreet Unit #• '".runt #: Sd ` /. ' }department: Butidmmg ( neltment Type: (PLain) (Plot, ENTERED FEB TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: AA/JAZZ) /Pee/9(4c Owner of Record: Assessors Map # '7/ Lot # d'(o Type of Occupancy: New: Renovation: Replacement: Plans Submitted: Yes X No Installing Company Name: /I%,,I ,' J,4 // 420. Y_ Company Street Address: / i4 44 i ,e-4 City: /l% i 49 Zip:e9k*W Company Phone Number: 978-69P-4,/ Estimated Cost: $ ore • L2 Indicate total number of units in the applicable box below Family Air 1 &2 Basement ,. o -a 2nd Floor 3`d Floor Roof . lc Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces--Oir6 Generators Other: Ada ,d�, Basic Building Code Commercial Basement 8 e- g u. (4 g u. Cv) Roof* Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: 1 certify that 1 have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in with all pertinent provisions of the Massachusetts State Build' Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexi 7,7 Signature: � � A /W4, ,c e)07596' Print Name: Type of License: License This Section for Offical Use Only Permit fee: Receipt #:7500 Revised 12/31/09 aja Approved Dates? i7/D Date Received: Received by: Permit Number: !) eo x.46 Map #: Lot #: Unit #: Street #: Street S tre Pero 3f Documefl /0 Perm ;.. /dale- die-4 /lie-t- Ae -ems �a �e- Map #: Lot #: Unit #: Street#: titreet Name: / f,'/ i) R Treet Unit #: rmit#: 9 L z Department: Buthi D'ocilment Type: P !uaa' TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781-862-0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 12 BASKIN RD Owner of Record: FRANCISCO SILVA Assessors Map # Lot # 9/ Type of Occupancy: RESIDENCE New: Renovation: xx Replacement: Plans Submitted: Yes No xx Installing Company Name: FEDERAL HEATING & ENGINEERING CO., INC Company Street Address: 1 60 CROSS ST City: WINCHESTER Zip: 01890 Company Phone Number: 781 - 721 -2468 Estimated Cost: $16, 000. o0 Indicate total number of units in the applicable box below Basic Building Code Commercial 1 & 2 Family Basement °o N , — _ °o `� C N 3rd Floor Roof Ground* Air Handling Units K Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners x Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement L o ir. i °o u- C N o . M Roof Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: fr Signature: /9 c THOMAS LAPOINTE Print Name: UNIVERSAL Type of License: Lice 0 00 1 615 7 9 Permit fee: /94. d Q This Section for Offical Use Only Date Received: cf00 Issued By : rikeproved Date: d�� O 0".A1 Receipt #: 9 Received by: Revised 12/31/09 Permit Number: /9 ,,,, f P jj,(y3 iday_ /_ep_4 lieu[- \.7/71-c-d-/ A-4_/ Map #: Lot #: Unit #: Street # street Name: /57-%5 P 3 .Treet Unit#: ',mutt #: --78 Oepartment: Building Document Type: tt iFlc2t; (Perm I TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 3 Q {e s Owner of Record: ; yO Assessors/ Map #(7Lot # Ty e of Occupancy: f eldrij sa,t New i/ Renovation: Replacement: tZ Plans Submitted: Yes V No Installing Company Name: He-01 Company Street Address: Z `�; �� M Pc ty: toy, (Aim_ Zip: fW Company Phone Number: ) _ 7 ... 3e 2. - 082 Estimated Cost: $ t�l 00 Indicate total number of units in the applicable box below 1 &2 Family c E U) 0 0 0 u- N? 0 0 ti 0 0 0 c 2 . Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners, Ventilation Fans Energy Recovery Ventilators Furnaces - so p Generators Other: Basic Building Code Commercial Basement o u. , 00 1'- N o Li. V Cr) Rood` c 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington., Signature: .,QO ,,MtbA Print Name: 4 6 1r: /5:3ai License #: Permit fee: 906 Issued By : Revised 12/31/09 This Section for Offical Use y Receipt # /Z 1 Date Received: 7/9 40/0 raft jais Approved Date: Permit Number: 740a/ Received by: Jiti(A Aar- if-6J zitir,t- \-/Ak-d Map #: __2 Lot #: Unit #: Street#: s>treet Name: g.4777—Z- Err 4w,F =reet Unit #• jernl2t #: a� 0 Oepartment: Type: (t [ ) (21.21) l Fertn) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: ;2 v a-A.44e tf Ave . Owner of Record: Assessors Map # ac Lot # N Type of Occupancy: New: Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: /Trek/tic t Fircp/ t e,_`_) Company Street Address: /5 C Ion, , fir- City: f= /4 ,,,,vos tet,L Zip: Nil- 0 8gz Estimated Cost: $ 02 -' Company Phone Number: 42t).3 Indicate total number of units in the applicable box below 1/W1& 2 Family Basement 0 L °o fV °o M Roof Ground* Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: 4j c);11 cf v,tvrt -6Pe 14(.4 Basic Building Code Commercial Basement $ u- N r- °o L- C N °o _ u- U cn Roof'* j Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: dppIKinci. t lenhei n091y + rjS ri /e- 12, 04444/3 Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed u er e permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State it o$ the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexingto Sig ture: Print Name: 6,-,,..044:e /f Nfl Type of License: /3/ 83-7 License #: This Section for Offical Use Only Permit fee: 3e 'Receipt #: a 904 Date Received: 47,/ 14 47 Issued By : Approved Date: Revised 12/31/09 Received by: ceijp Permit Number: /0 The Commonwealth of Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): AT 141 rc 1 f� Address: I S Colo v i a . are, City /State /Zip: IE • a mskRd M14 Are y an employer? Check the appropriate box: Are a employer with /'/ 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub - contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.x required.] 5. ❑ We area corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Phone #: ( -3(v 1-" a0 Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. [Other 44(1—.. *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.4Q J t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new aavit 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.. c Insurance Company Name: G Policy # or Self -ins. Lic. #: t c 1 S'(5-8 ?3 Job Site Address: Aga ga/TL T 4ye- City/State /Zip: `,,e h Expiration Date: 121 C412-0 1 O Attach a copy of the workers' compensation policy declaration page (showing the policy number end 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 cert u th a" and pe ties of perjury that the information provided abov is true and correct. Signature: Date: 6 __ /d Phone #: -.7(e2,— en) z a 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: ACORD� CERTIFICATE OF LIABILITY INSURANCE ■ DATE (MM /DD/YYYY) r 6/4/2010 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 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 The Driscoll Agency, Inc. 93 Longwater Circle P.O. Box 9120 Norwell MA 02061 CONTACT NAME: PHONE FAX IA/C,No,Ext►:781- 681 -6656 (A/C,No):781 -681 -6686 ADDRESS: jbd @driscollagency.com PRODUCER CUSTOMER ID #: 5702 INSURER(S) AFFORDING COVERAGE NAIC # INSURED Architectural Fireplaces of New England, Inc. 15 Colonial Dr. East Hampstead NH 03826 INSURER A: Peerless Insurance Company 24198 INSURERB:The Employers' Fire Ins Co. OCCUR INSURERC:ACE Property & Casualty Insurance INSURER D : 12/30/2009 INSURER E : EACH OCCURRENCE INSURER F : COVERAGES CERTIFICATE NUMBER: 378561024 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 N SR S W VD POLICY NUMBER POLICY EFF (MM /DDIYYYY) POLICY EXP (MM/DDIYYYY) LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY X OCCUR CBP8365065 12/30/2009 12/30/2010 EACH OCCURRENCE $1,000,000 DAMAGE PREMISES (RENTED occurrence) $ 100,000 CLAIMS -MADE MED EXP (Any one person) $5, 000 PERSONAL &ADVINJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 7 POLICY X PRO- LOC JECT PRODUCTS - COMP /OP AGG $2, 000,000 $ B B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS FB1E08033 - MA Auto 7530190680003 - NH Auto 12/30/2009 12/30/2009 12/30/2010 12/30/2010 COMBINED SINGLE LIMIT (Ea accident) $1, 000, 000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X PROPERTY DAMAGE (Per accident) $ X X Coll w/ Waiver Ded $500 Comp Ded $500 A x UMBRELLALIAB EXCESS LIAB X OCCUR CLAIMS -MADE CU 8669202 12/30/2009 12/30/2010 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 DEDUCTIBLE RETENTION $ $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS Y / N N / A NWC C45865873 12/30/2009 12/30/2010 X WCSTATU- OTH- VIPs ER E.L. EACH ACCIDENT $1, 000, 000 Y E.L. DISEASE - EA EMPLOYEE $1, 000, 000 below E.L. DISEASE - POLICY LIMIT $1, 000, 000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Notice of cancellation provision is 30 days, except 10 days applies for non - payment of premium. CERTIFICATE HOLDER CANCELLATION 30 Town of Lexington, MA 1625 Massachusetts Avenue Lexington MA 02420 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD jitic4 die)a Map #: Lot #: Unit #: Street #: street Name: 731200 ST . ;rreet Unit #: '?rmit #: Department: Building i)ne '!mein Type: tPbni (Pk (Perm TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 -862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a BuildingPermit FEE: $12 per one thousand valuation or any portion thereof Property Address: 7c g I /d 5/- Owner of Record: 3p - S l % (/' Assessors Map # 7 Lot # Type of Occupancy: New: Renovation: Replacement: X Plans Submitted: Yes Installing Company Name: [ I' fe, fos . r%/t C. Company Street Address: I erxid 6,% Y City: tatkwidce , /44 Zip: C gef Company Phone Number: %' c%�" DD Estimated Cost: $ Indicate total number of units in the applicable box below M 1 & 2 Basement p QL CJ N L O 4.. it C C7 Air Handling Units N. Hydro Air: Unit Evaporative Coolers Kitchen Vent & Exhaust Equipment Heat Pumps Pool Heater Range Hoods Vented to Exterior Process Piping Refrigeration Units Roof Top Units Central Air Conditioners X. Radiant Heat Ventilation Fans Hydro Air Systems Energy Recovery Ventilators Central Air Conditioners Furnaces= Oil Other: Generators Other: Basic Building Code Commercial Basement g LL s $ u. c N o c u E CO Roof Q v Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units X. Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information i have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all >laws /bylaws /regulations of the Town of Lexington: Signature: RoMfdJ � - Print Name: re5.Sri Type License: 6 R C /o" t $ License #: This Section for Offical Use Only Permit fee: Receipt #:J�p, Date Received: 6'=/ 4 76 Received by Issued By : Revised 12/31/09 Approved Date: A510 % Permit Number: (�o CO The Commonwealth of Massachusetts Department of Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly jfe , rosy Name (Business /Organization/Individual): Address: �'f , (c' i 604. City /State /Zip: k 6 Phone #: Are you an employer? C eck the appropriate box: 1 [,I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub- contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub - contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.# required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. [Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.0 Other *My applicant that checks box #1 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 Contractors 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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State /Zip: 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 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 under the pjains and penalties of perjury that the information provided above is true and correct Signature: Phone #: Date: /q/ AO' 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, 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 is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing 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 than 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, §25C(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, §25C(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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(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 Town 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 home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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 Revised 4 -24 -07 Tel. # 617 -727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617- 727 -7749 www.mass.gov /dia off' /cam /Jar_ i-/-4661 pet nr <uc. �i � �U Map #: Lot #: __ 5 Unit #: Street#: 3 3 street Name: lLG/(� w_ S7 ,greet Unit#: '?rmit #: /d35— Department :3(�ti(l DAC, /Merit Type , tl"( .n f (��Ot) Penn) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PE'; T 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 33 f % Owner of Record: Sea or,- ( r avi Assessors Map #5 cir Lot # 115- Type of Occupancy: Per/ ,re New: )( Renovation: Replacement: _ Plans Submitted: Yes No Installing Company Name: C a t Cod i4 r14; ,tenC Company Street Address: 9 AJ, la f/e 3t. City: G t'WburtiZip: oifO/ Company Phone Number: mod/ - Vs - K.z (1t° Estimated Cost: $ 2jj Indicate total number of units in the applicable box below 1 & 2 Family Basement L _ °o u- N O o " 2 N L _ °o " E co Roof c 0 O 6 Air Handling Units Generators Hydro Air Unit Draft Inducers Oil fired Equip Evaporative Coolers Kitchen Vent & Exhaust Equipment Heat Pumps Pool Heater Range Hoods Vented to Exterior Process Piping Refrigeration Units .. 1 Roof Top Units Central Air Conditioners III Radiant Heat 2 Ventilation Fans Central Air Conditioners Other: Energy Recovery Ventilators Furnaces- Oil boa er / Generators Other: Basic Building Code Commercial Basement 1St Floor 1 2nd Floor o u_ p co ° O Ce Ground` Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping .. 1 Roof Top Units III Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be.required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: O. I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above applic- • is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations • - rform: d under the permit issued for this application will be in compliance with all pertinent provisions of the Msachus -tt ote B ding Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of igoon' . rr` ( rarxs -c- (r)0 — lc-137M Print Name: gna re: Type of License: License #: Permi fee: 3o o _ co Issued y Revised 12/31/09 This Section for Offical U e 09,ly Receipt #: 534 f Date Received: 7 /Ay /ro o Approved Date: 'I( rIL 1 1 Received by: Permit Number: I0 (075 j,4y) ple_ die-4 7/ti-t• Map #: Lot #: Unit #: Street#: 7 / street Name: ,,1rF,7,0 �%�' ;meet UnDt #: '".rinit #: ¢department: 3 ct i ding Document Type: t U at als2t l TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 7/ Bey' e-e s! Owner of Record: n (.4(AA rofy Assessors Map # 1 Lot # / Type of Occupancy: New: /Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: ,M X 1 a /9&( B %tr Company Street Address: ,2 70 /4R'107 -5 City: dt/ -c RO/(' Y Zip: Company Phone Number: /7 2 -C-Cg ^'� % Estimated Cost: $ Indicate total number of units in the applicable box below 1 &2 Family Basement] 0 ti r 0 u -cs 3.d Floor Roof Ground* 1 Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners �% V Ventilation Fans Energy Recovery Ventilators Furnaces - Oil Generators Other: /6 Oo c:, Basic Building Code Commercial Basement I .lootd Is 2nd Floor o u- co 4.. S it Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: `Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information 1' have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Signature: -2-vii/K/47 Print Name: ,ems Type of License: /30723 License #: This Section for Offical Use Only Permit fee: �' C� Receipt • Date Received: /,3 -4 Issued By: proved Date: 11(2_ Revised 12/31/09 � / 2.Zty Received by: G1,%�'a�'j • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information p Please Print Legibly Name ( Business /Organization/Individual): /4/ ` `�y ' ° PC ee"67 ti Address: a70 - p,oe ROA!T 5! City /State /Zip: GO' CT EoXdu £ V Phone #: (c/ 21 5'3 ocfg- Are you an employer? Check the appropriate box: 4. 0 I am a general contractor and I have hired the sub - contractors listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.: 5. 0 We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] 1. UV I am a employer with employees (full and/or part-time).* 2.0 I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t Type of project (required): 6. 0 New construction 7. 0 Remodeling 8. 0 Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other *My applicant that checks box #1 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. Contractors 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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State /Zip: 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 c. 152 can lead to the imposition of criminal penalties of a fme 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 fme 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: rer ,/. _Y9e— 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, 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 is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing 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 than 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, §25C(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, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfonnance 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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(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 Town 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 home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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 Revised 4 -24 -07 Tel. # 617 -727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617- 727 -7749 www.mass.gov /dia t "alL_ Nj/k—d.../ Map #: Lot #: Unit #: Street #: street Name :, Beet Unit #: '<'.rmit4: 3- 87= i Oepartanent: i) zestment Type: 121, (Perm TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781-862-0500 x -211 Fax: 781-861-2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: (, B a a kd god AC Owner of Record: Pa-3-c ��s {� � 1 n Assessors Map # j $ Lot # g7 Type of Occupancy: r--,sic •cA New: x Renovation: Replacement: Plans Submitted: Yes No X Installing Company Name: Lc \-;- c-t1;t Cot, I , -\,L. ,,.,� ;fin e. Company Street Address: N , nip le s.F City: 0,[,m Company Phone Number: 7J i - 9` ?] ,p ,Ffy Zip: a /Ay Estimated Cost: $ 2-4 Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement 1St Floor 1 JOOI% puZ L 0 . Roof Ground* Air Handling Units Y Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: Basic Building Code Commercial Basement °o LL o LL LL a N °o v M Roof* Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the M. - sachusett to Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of 1 /'L 'ngter, gign ture: Perms fee:9(4.(V Issued Revised 12/31/09 rint N me: Type of License: his Section for Offical Use 9nly Receipt #: ,27 (g Date Received: 6 /$ / /�� ..�.t Approved Date: 6 // /v 67W, is 13 ?rn License #: Received by: Permit Number: to , G05- / Miff wat WOrkers" Coalpensation Instir.n (.:e Affidavit:: Builders/Contra.etorsiElectricia.H.s1Pit/m.krs. .A.:12.0.041,114,911P,1;at.1121Y . . . . _ Ltkibb! The C'ontniahwealth of MUSSaChasetts Deparirnen 6j- Industrial AcCidetit!: Office of investigations (.410 Washoti: Stree( IL Map # Lot Address: Pet-dd.' 1,1 (Ftuririessferipiritzatiortlirdividtist): 1". • (- „„ „„, _ . € 110 21-1 employes Chccil the 4ppropriate J.n 1 am a employe !. with employees (full and/or part-time).* 2. L..) I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.) 1 am a homeowner doing alt work myself. [No workers' comp. insurance required.) box: 4. fl 1 ant a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers' comp. insurance.4 We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] 5 0 Type of project (required): 6. 0 New construction 7. 0 Remodeling 8. Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.D Plumbing repairs or additions 12.0 Roof repairs 13.M Other irt.rh-kt *Any applicant that checks box #1 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 contactors must submit a new affidavit indicating such. 1-Contractors 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. am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. 73,SUran cc- Company Mane Policy or Se,J.Clus. i`r: f■lx.pirretionDat:_ ob S e Addes:1 06( c4,4A- Citylstateizi-d: 1.e Kt )7, /9 /9 Attach. a copy of:the workers toinpensnion policy declaration page, (showing he policy number and expiration 121.6). utt secure covetagr Couirc under ticn 2$A of 1001, c. 152 can lead let the irri,)0Sitien penalties c.if a line up to ,S1,500,00 and/et ottc-yt imprisonment, its well as eiyil plialties in the form of a S1 OP WORE ORDER and a fine of tip lc 250.00 a day actablEi lh violatin. be advised that a copy of this etatentent may Lc, fovt,s1-6,ed to the Office of Investions ef the DIA rbr insulance edveiage yerification. 1 ‘1,7 hetet) ler the pains' and penollie5 ofperkty that the thfOrmation provided above i ruc: nd correa Sitrattlt e: Datt: 4a Phone Official use only. Do not write in this area, to be completed by city NI official City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2, Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other [ Contact Person: Phone ti: n furmaton arot Ivlassa,cnusett.i cliapte„i 1.52 requires ail erriployers,..10. viol:kers' compensation for theiy.- emplo37-tes. ciejimeci in the scavice anetho- bona-act XID.J;E'S.1 Gl.al or eiliptOyeri.?. defined at "an. indivichial, oier hij tci 1 (;:inpcniation. oi legal ii1Is. CT any tAVO Or rilOrK(: of the foregoingbengas.g.ed ii a.,..ioint enterpriser and . including. the legal. tepies.entaiives of a cieceased employer, of the receiver or tu.st.ec of an, individual, parmership., sobiation. or. (Abet. 1.0gt). (;ntity ermAc,yirig mplpyees%.. fi.3„:(Avevei oi.7 Owelling jn 01 zbarl apartmenv. and: resides tbencin.„ or U 3c uait oi ft.1e2 dwejlittf= iic).1.,0::t.t abothe:,..:. c;ons-u:-uctio3 CM. silch d-Weiling "usrqq.. E:q1ch. diecip.-A to -be an F tiac: renewal of a license or permit to wer'ate busines's cr' to cior.,,struet buildings: fu. r coinnionweal.th tor an■., ppIiciit wbe has net produced acceptable evidenc e. of colnpliauce with the insuira nee coverage required." Additionally, MGL cha.pter- 152, §25C(7) states "Neither the corranonwealtb no 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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply subcontractor(s) name(s), address(es) and phone number(s) along with their certificate(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 o if You are required to obtain a workers' compensation policy, please call the Department az the number listed below. Self-insured companies should enter then self-ins mance license nurnoti on the appropriate lint_ Cay or Town Officials Mean be &me that the affidavit is complete and printed legibly. The Department has provided a space at the bottom he EffidaVit fOI you te, ffifoM, in the event the Office of investiga tioni has 10 ‘013t0 d. yoh regarding the applicant Please he surf., filj in the ucriniti/icente, numbei which 1.u.ce as a I do eD irt,0")t?.. fp Fddition, pr applicapt that fans; submit multiple permit/license, applications in any yeal, only subnin ohe affithrvi'i juin:bating ctuitin policy inforraion nccessaiy) 21-.1d under "Sob Site Address" the applicant should write "all locations in (city cr tov,r4"" A copy of the affidavit that h6F boon Official/3, stamped or marked by the city et lown may be provided to tbei applibant 10. ;1. 04).f that t Valid afirfeAt ie; tik for Mare pormitf, 11.r,exiseF„ A pew zfildavit :nu 1\ filled out each V0?. Wnete, abhome owner 10 ciiis?,eli is obtaining a lieenie peimit nbi,Ief!atitd to any business 01 COnillelCial venture dc,g lie;e1T,2e or permit to bnn legve;e etc-,,) said :PM.,";013 n e-opired 100 opleie this affiaavit. r he Office of Investigations would like to thank vou 0 advance: !RA you coopoiation L0 should you have any clues:60w; please do not hesitate tp give; us a call. 'The Department's address, telephone, and fax number.: The Coraraoriv,zWth. of Massachusetts Department or Incivstria AoCidents Office of Irrkstigations 600 Washington Street Boston, 1\4A. 02111 ;Revised 1,1-22-06 # 617-727-4900 ext 406 or 1.877- Fax #i 617-727-774 V,WW.TYI ass o vid ,fit "7" \Y/C—J./ Map #: 3 • Lot #: Unit #: Street#: itreet Name: _?Teet Unit #: ',;rmit #: r 02 Oepartment:3«�iti!n, Document Tyne: (Petal) (Plo, (Perm) ) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781-862-0500 x -211 Fax: 781-861-2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: . Assessors Map # New: / Renovation: i -4, 4 v 0 Lot # 2_8 Installing Company Name: Owner of Record: h r; s for /ter Ne u rattl Type of Occupancy: s iN, (e :.( re-14e f Replacement: Plans Submitted: Yes ✓ No h0trvt Neu (ei Company Street Address: 2 ( (' yw c'1 ?4 'e City: L .en� 43 MA Zip: 0 '+ 2- o Company Phone Number: 31-60-- c S/ 2 Estimated Cost: $ 3 5-0 0 Indicate total number of units in the applicable box below 91:1 r".; + C r Basic Building Code Commercial 1 &2 Family Basement J _ °o u_ m o o c 3rd Floor Roof c O Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: 1a w t ie(0 -t 2 3 91:1 r".; + C r Basic Building Code Commercial Basement 1 o LI m �- 0 L 2 N o LI '2 M L Roof* a OL 5 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: This Section for Offical Use Only Describe Project: `Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By-Law: i �j �/ ° it [., Ter 11'4-611 be ryr�t�� T 81A ( J 14 14,,. t1t- kr4Yh r ao iu - rS wi T oeLv 2_V ,4Ps hausz a i , l o vi I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: /1n %Uro101ntrt'ur A1/47 li [ o,e cwkr) Signature: Print Name: Tvpe of 'cense: License #: Permit fee: &-I$ co Receipt #: ,;,2 66b Date Received: "24_, to Received by: 4. Issued By : Approved Date: 7/2-7 /1D Permit Number: I®_ 83 \ Revised 12/31/09 21 Byron Ave Mechanical Permit details: Heating radiators and piping for 21 Byron Ave house addition. Building permit on file ( #09 -678). Four additional hydronic heating zones for addition's: bathroom, family room, study room, basement room. Runtal wall mount radiators, piped with PEX in home run layout. Manifold with automatic zone valves and one variable speed (microprocessor controlled) Taco circulator pump. Each room wired with electrical thermostats. System tied into existing boiler. Also one Panasonic bathroom ventilating fan installation. vim, r�rZ duo 7A<t Map#: Lot #: Unit #: Street #: 4treet Name; ,rreet Unit #: 'ermit #: Oepartrnent: Bunkag . Diootment Tvpe: (i Etn) (Plot) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # Property Address: C,v2©G ry c.— Owner of Record A/144,16/e- ,--- Assessors Map # ( Lot # f Type of Occupancy: �� f New: Renovation: Replacement: ✓ Plans Submitted: Yes No Installing Company Name: 6 , ' ' /c-- Company Street Address: / i9 City: / J4y 4 ,V4.- Zip: (2,2 8 / 9 Company Phone Number: 52)(Y- ?A) Estimated Cost: $ /e) x ? Indicate total number of units in the applicable box below Basic Building Code Commercial a) E a) co 0 u- 0 0 0 w N 0 0 0 0 c 7 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & EA-must Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation In urance A ■`■ avit re ' uired for all mechanical submissions �i..illl>r ian -'�'e. e s 4-ae/ly V1 j L /30? Print Name: Tvpe of License: License #: This Section for Offical Use Only Date Received: it; r Issued By : Approved Date: .08 Permit fee: 49,D. tO Revised 8/4/10 AC Receipt #: ?-7 Received by: X. Permit or Alteration Number: /0-(Old 1 &2 Family Basement 0 0 � c' 0 0 LI N o 0 I M Roof c c 0 2 0 Air Handling /Hydro Units Evaporative & Refrigeration Coolers Heat Pumps Range Hoods Vented to Exterior Central Air Conditioners Combustion Air Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Other: 64 s- 0, .1., Basic Building Code Commercial a) E a) co 0 u- 0 0 0 w N 0 0 0 0 c 7 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & EA-must Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation In urance A ■`■ avit re ' uired for all mechanical submissions �i..illl>r ian -'�'e. e s 4-ae/ly V1 j L /30? Print Name: Tvpe of License: License #: This Section for Offical Use Only Date Received: it; r Issued By : Approved Date: .08 Permit fee: 49,D. tO Revised 8/4/10 AC Receipt #: ?-7 Received by: X. Permit or Alteration Number: /0-(Old Mir d46J,�t • /iteeze_ \A-<-0-/ Map #: Lot #: Unit #: Street#: ',;ti-eet Name: ;rr-eet (Jnit #: 2. /2 —472 �Y. Oepartment: €3c�rlcl_ni Doetnnent Type: (P!tn) (Plot) (Perry) `� TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: eq, r1 'de Cleit. Q' Owner of Record: t(,es . Qri /Ape.- Assessors Map # /g Lot # /lc A Type of Occupancy: res.' ch 1 I New: Renovation: Replacement: Plans Submitted: Yes Installing Company Name: 40 Li ' //y fhAi 41, Company Street Address: / a7t ,- a City: le, 4, Company Phone Number: 7g--- '/77 --0 74/0 Indicate total number of units in the applicable box below Air Handling Units" Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil c m E m rts m 0 0 `0 0 u. CV 0 0 L 0- cc c z o, 0 Generators Other: 4 5 40 4. 2 20hes Basic Building Code Commercial Basement o `' 0 u- N. ' o u. C'7. Roof c _ ` 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust, Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Leliin ton's loise By-Law: 9 (o certify that 1 have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Ma us s State B ilding Code, the international Mechanical Code, and all laws /bylaws /regulations of the Town of ington: Print Name: ype of Licen e: License #: This Section for Offical Use Only Date Received: 5 j iro fro ermit fee: 7,,?. co Receipt #: g6g 36 4O Issued By : Revised 12 /31/09 5-46 0 a_ Approved Date: 5- Received by: Permit Number: 10 t{ J.,ILicA diza Map #: 3- 8 Lot #: -4 7 Unit #: Street #: 4treet Name: --- 12,¢/2 Sj Treet Unit #: y � Oepartment: 0.1••■■10 la // Document Type: drt .n) (Ftoi (Fermi) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 - 862 -0500 x -211 Fax: 781 - 861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # Property Address: Owner of Record: in G n 1 5) ,P(,, car Assessors Map # 5—S Lot # �'� Type of Occupancy: r,a L %� tr7 1�'' NO New: ,>< ` _Renovation: Replacement: Plans Submitted: Yes No X Installing Company Name: / / &,,,,t- no Company Street Address: /7 /-y:-.1 4t _ .... City: tx)ei.' Zip: 0 4 ,' Company Phone Number: (;• 7>e e ` ?� /- f`??.7 Estimated Cost: $ z', Oc�.-) Indicate total number of units in the applicable box below j/Famu1y INI 1 & 2 Basement 0° 2nd Floor _ °o " M Roof c 2 0 Air Handling /Hydro Units l Evaporative & Refrigeration Coolers Heat Pumps Range Floods Vented to Exterior Central Air Conditioners Combustion Air Nentilation Fans Energy Recovery Ventilators Furnaces- Oil Other: Other: Basic Building Code Commercial Basement g u_ ,- 2nd Floor o 9 co Roof* Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & E)aust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: / / / C..czxrJ )5` ,t- 4.41,'/ , ') {f % ?�� �S t(t. i f i,.5; 1, ectf % �K°i �C /i i ko �x t,) /i (01T-v4 I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation Insur e Affidavit required for all mechanical submissions / X 9 P9 .2-,S Cam . '� ✓9/ ✓ CJr / ��v !nc d Tvoe of License: Signature: Print Name: License #: Permit fee: % b Issued By : Revised 8/4/10 AC This Section for Offical Use Only Receipt #_� 72 Date Received: l0f$1/a Received by: 110 pproved Date: t Permit or Alteration Number: (0/ 12-1/ t13'l The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Address: h LA-"%f r:%✓r? City /State /Zip: Louic,l) rn R C)tzS,�J Phone #: 76 - 76/ - f 6 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I ,employees (full and/or part- time).* I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 5. ❑ have hired the sub - contractors listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.t We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.Other /Vw) Ouctwor k i-hdroA,ir *Any applicant that checks box #1 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. $Contractors 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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City /State /Zip: 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 c. 152 can lead to the imposition of criminal penalties of a fme 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 fme 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 tptder the pains anddenalties of perjury that the information provided above is true and correct. Signature: Phone #: Date: 70C TI l 979 76-/ -01 Sa 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, 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 is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing 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 than 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, §25C(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, §25C(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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(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 Town 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 home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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 Revised 4 -24 -07 Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617 -727 -7749 www.mass.gov /dia Pr' te-4 Art- Z)/Ire- Map #: / 3 • Lot #: 3 -3 Unit #: Street#: r6 'treet Name: C4E-G 6,44/� Treet Unit #: Department: Building i)cctui)ent Tvpe: tpt 2i (plot) ('Perm TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 - 862 -0500 x -211 Fax 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a BuildingPermit FEE: $12 per one thousand valuation or any portion thereof Property Address: 3(, h ,Owner of Record: Assessors Map # t j Lot # 3 3 3 Type of Occupancy: New: ✓ Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: tfa(atekrt 5 a ct`4i (It)tAC ricA Company Street Address: 33 4 .. wk.km,r] ss"City: VO,cc9,7-D Zip: Data 5S Company Phone Number: Co 1 7 778= cio Estimated Cost: ', •'` (k a i Indicate total number of units in the applicable box below 1Jr1&.2 Family Basement 1 8 S 31.d Floor 1 Roof Generators Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: Basic Building Code Commercial Basement 1 $ ' LL , o LL _ c t g` u. �) 8 3 Ci Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that 1 have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Signature: Print Name: Type of License: ?-5q iR- FgSq a° 33 (%b License #: This Section for Offical Use Only Permit fee: / Recei Date Received: Issued By : pproved Date:3 tU 3 w [TO Revised 12/31/09 Received by: s Permit Number: 10 _ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 WWW.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers' Applicant Information Please Print Legibly Name ( Business /Organization/Individual): `��U�`t Wk 4, 7-1X yo/y Address: 3 3 4 11\MLI 1 ecS 2?oca Oats City /State /Zip: t j . ) J . ., Phone #: Cfl l 7 Are you an employer? Check the appropriate box: 1.0 / am a employer with employees (full and/or part- time).* I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. 0 I am a general contractor and I have hired the sub - contractors listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.* 5. 0 We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. {$rNew construction 7. 0 Remodeling 8. 0 Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other *Any applicant that checks box #1 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 *Contractors 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. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City /State/Zip: 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 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. 1 do hereby cernfy under t„ ins and of perjury that the information provided above is true and correct Date: E • lb Phone #: Ka 17 • 7 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, 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 is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing 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 than 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, §25C(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, §25C(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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(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 Town 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 home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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 Revised 4 -24 -07 Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617- 727 -7749 www.mass.gov /dia but Map #: • Lot #: Unit #: Street#: 4treet Name: Treet Unit #: C®/VCO2Q 1) VE 10 '7' 0 Oepartrnent: Bttil<iing Document Type: (P h. ) (Piot) Peranl TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # Property Address: z z n C-d e" 1 vL Owner of Record: C kr t -S 1 e/4 Assessors Map # %I Lot # % Type of Occupancy: tees New: \ Renovation: Replacement: Plans Submitted: Yes No l/ Installing Company Name: b./ - /3 c •-� os VA- C Company Street Address: 35 L IrArkCCity: I? Ppc r ( Zip: 01 y (9 3 Company Phone Number: '7K - 3 3 - 3 ^? 3 Estimated Cost: $ a 3 Indicate total number of units in the applicable box below Family 'VI 1 &2 Basement 0 0 CZ .' 0 0 u- N `o o U 2 M Roof 1 a c ° U' Air Handling /Hydro Units Evaporative & Refrigeration Coolers Heat Pumps Range Hoods Vented to Exterior Central Air Conditioners Combustion Air /Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Other: Other: Basic Building Code Commercial Basement] g u- Lmold P„ Z o M L..punao Generators Draft Inducers Oil fired Equip Kitchen Vent & E>diaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Workers' Compensation nce Affidavit required for all mechanical submissions L� /z G 6/7, ,' r 1 f, r-r /z Pz- / 5 5L/ 1 Tvpe of License: License #: Signature: Print Name: This Section for Offical Use Only Permit fee: J:76.6) Issued By : Revised 8/4/10 AC Receipt #: Date Received: 244'o Received by: # roved Date: t2- f Permit or Alteration Number: JAA /day- die4 te_eze_ 7/1-c-d Map #: Lot #: Unit #: Street #: 0 street Name: ro/ve0,0 , v Treet Unit #: Z Department: Budding DaerFT!leitt Tyne: (p(o1 IFtc?t> (Perm TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is N OT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: t eQ1U931Qi Owner of Record: 'r % AO/Wee-cif Assessors Map # Lot # Type of Occupancy: e- (if rtJ'' New: Renovation: ✓Replacement: Plans Submitted: Yes No Installing Company Name: } (Z , Company Street Address: 2 C°„RoSC-W---tity: Zip: YA f t Company Phone Number: (1 9/6 - p 2 2. f' Estimated Cost: $ feC Indicate total number of units in the applicable box below c E N ca m 0 0 L `0 0 LL N 0 0 LL M o- 0 c CC 2 Air Handling "Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other Basic. Building Code Commercial Basement o li n T.- o N` 3rd Floor $ CC Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool; Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems VW Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a' Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws/regulations of the Town of Lexington: / Q . , - J , e , oe..) u Signature: Print Name: Type of License: License #: This Section for Offical Use/Only Permit fee: / $�() I Receipt #0 7/47 %'I Date Received: -7 40 Issued By : Revised 12/31/09 Received by: Approved Date: i [7,24a Permit Numbers 10 _ g TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: '2 e6iQc/ fiieOwner of Record: "MX) Assessors Map # Lot # Type of Occupancy: ((f x,19 New: Renovation: t -Replacement: Plans Submitted: Yes No Installing Company Name: 2 Company Street Address: ?9 , cjvt4ity: 01-4-1 Zip: XXI Company Phone Number: ( 9/6 ? 2. Estimated Cost: $ try Indicate total number of units in the applicable box below M 1 &2 Family Basement 1 Jo0Id I. 2nd Floor 0 M Roof Ground* Air Handling Units Hydro Air Unit A/9 Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement 1 o LI v. g II a c N 3rd Floor Roo? Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a.Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Signature: Print Name: Type of License: License #: Permit fee: This Section for Offical Use Only Date Received: `7 /221 0 Receipt #02b, jsc- Issued By : Revised 12/31/09 ."4 Received by: . 0 c_. Approved Date: I j t Permit Number, to - g &l:AA 7,/4 Map #: Lot #: 02 Unit #: Street#: 'treet Name: C7 S% Treet Unit #: j�rm,t4: g /3 i3 9 Department: B i d n2 Document Type. f 1PL n) (F!c!t ! TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781-862-0500 x -211 Fax: 781-861-2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? Property Address: 5 Ca e Owner of Record: F-7QIle/' Assessors Map # Lot # Type of Occupancy: Scr6 -C New: Renovation: t,'-Replacement: Plans Submitted: Yes No Installing Company Name: G-raki o Company Street Address: 3 3 0 SOuFl► 2d City: Zip: fO/ 2 30 Company Phone Number: l ° & ( - „275--t2 3 3 Estimated Cost: $ Indicate total number of units in the applicable box below Basic Building Code Commercial a) E W 0 0 L 0 0 N 0 0 u- M 0 0 ec c 2 0 Generators Draft Inducers OiI fired Equip Kitchen Vent & Eaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation Insurance avi equired for all mechanical submissions 41/4 / S7/7ccrel SAee/ Ale A4f Tvoe of License: Signature: Print Name: .22o? License #: This Section for Offical Use Only Permit fee: Recei Issued By Revised 8/4/10 AC Date Received: w /r5 Received by: Li pproved Date: ID l D Permit or Alteration Number: 1 &2 Family Basement 0 7 2nd Floor 3rd Floor Roof Air Handling /Hydro Units / Evaporative & Refrigeration Coolers Heat Pumps Range Hoods Vented to Exterior Central Air Conditioners / Combustion Air Nentilation Fans Energy Recovery Ventilators Furnaces- OiI Other: Basic Building Code Commercial a) E W 0 0 L 0 0 N 0 0 u- M 0 0 ec c 2 0 Generators Draft Inducers OiI fired Equip Kitchen Vent & Eaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation Insurance avi equired for all mechanical submissions 41/4 / S7/7ccrel SAee/ Ale A4f Tvoe of License: Signature: Print Name: .22o? License #: This Section for Offical Use Only Permit fee: Recei Issued By Revised 8/4/10 AC Date Received: w /r5 Received by: Li pproved Date: ID l D Permit or Alteration Number: idar dam"" A: r rekd t �� ,///%; "ar- Map #: Lot*: Unit #: Street # Street Name: StreeT Unit #: Permit *: Department.: Document Type:.1Pi 1P10t) 71 _4? TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: t ® �1ti 1 (91 Owner of Record: Assessors Map # 6/ Lot # 6f New: Renovation: Replacement: :forts= c Installing Company Name: i Company Street Address: City: Zip: Company Phone Number: to 6 S - 4 W� Estimated Cost: $ Indicate total number of units in the applicable box below Type of Occupancy: Plans Submitted: Yes No Basic Building Code Commercial 1 & 2 Family Basement I 00 u_ 2nd Floor 00 LL. co Roof c C) Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil v F 5:v.-t - :- ,.ce.. Generators rFr(-) Other: Basic Building Code Commercial Basement I S h , 2nd Floor I S c >i M Roof* ` = o 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: v F 5:v.-t - :- ,.ce.. rFr(-) /•l rv'� 7� /L Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: 1 certify that I have the authority to make the foregoing application and that all of the information 1 have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: nt Name: Signature: Cry r Type of License: License #: Permit fee: Issued By : Receipt #:' Revised 12/31/09 This Section for Offical Use OnI Date Received: /36 roved Date/: 02e /, / Permit Numb— /5/S( Received by: e narne: ' "r • ;41' ' ca.7.11.a..thIngrun Stly ( Woll'ef,PC ' silan•InwelvIce 47I'lf etrip.ew • • • • constructi6t;r6lige4irrr P.O. Sox 53 I " Plionc 4 1 am homeowner pc4formainc L4 wotk'myscif. 1 f:1 co!: proprietor and 1.-avc onc workint in any capacity. • 1 t::: cmploycr providinc )sorkers' CofflJQfl for my emploit c.:. workinc on rroc: Phone CIty: ComNny: Policy: 1 A:u proprictor, gcncral contractor, or lircowncr (circic onc) and havc Itircd L....-.1my who have the follmsint workers' comp4mation policy: Ccr.;-lany r_irne: • adz!rtf.s: nc Company; cc :ny furnc: Construction Specialties • Phone 37— 66 5----,-- Le Li ( c.. .). a •.1.:c.: Stoneham. NIA 02180 . city ._____ !:.....-....:::::c cott:pany: / IA) 5 .. C-0 .. • C), i / j__. i,./. “,,,ji. .A.....,:!1 ;t.iortal sliccts if ncccssary. ., /q,(1 0 — 8-( , 11 1 • 1...1:1....:c to s...7curc coveraEc as rcquirrd undcr Scion 2$A of ?.fpl .152 can lcad to the implcmcmation el •4 1:111 p:(11.1(1C4 of a !Inc up to S.1,500• 00 and / or one ycarii imprisonment as It as 60 r•Ca..1PiCS in . . i:,.: fra I -STOP %YORK ORDER" iAd a fiiic of SIC0.00 a d.ai 3C3.1/1.g MC. .1 undcau.nd that a copy cf .,!.itc Inc nc r.uy in forwardcd 10 the OaicC of InvcStitation of thc DIA for eovcragc vcrification., J., i:;.-c V CCf rib, wild& I. pain! :ir..:...1:urc of application: 1_,..4--1.--,....... er---' Dat: fall ?/(61 P.Ilo„e:-).g- ( C—L1V/ ° qty: Policy: ['boric Stittc: ' :tot Tit,: s:ca - to k complete,' by city et Permit s'; _ 1 .. r_imc: ,lrr1. rice: 1 a: :: l:ocuowncr per (orciinc all work nsysclf. 1 of :t to!: proprie(o( and lalTno'•one 11•oriinc in any capacity. a::' 1.1 c::t;t!o)•cr prvvidinc 1wtkers' cornh;rustion for my c.rrplo)iu wortcinc on t!us j•: �. Cc :;; 1 ^)' name: ... a .1 ".:.., to te1tIt 911 iul*In/;ron S:rw )1.`v "41..COnI we .rdfan •/n r vies: ct .(9; ;!: n •!r ConStrUCtidri i 11T il'C1D1,Y P.O. Box 53 Pbonc Phone Oir .:r3a';c Company Policy: — ! Am so!: proprietor, central contractor, or hgf(tcowncr (circle onc) and tare hircd t!t: Cn "t ! : t.;low who tart the follolsinc workers' corn lion policy: tees 1'drw Com;lany name: Phone - ---- -_ qtr. -t -c CbmNny: Cc y r,• Construction Specialties ---R Stoneham MA 02180 Pol icy: Phone Stitc; Citn State: Company: L��T` --r— UNl y� )c"IR� .__�� •� L S�.,jt/ i / shc<ts if nccc wy. Go ' Q' /� g- / U l ,��� 16 crate ai requtrcd under Scction 25A of MCL 152 can lead to th plc e t .:rultics of a talc up to 51,500.00 end / or onc ycari' imprisonment as well as civilm n_lltties in (:.. fort: a `STOP WORK ORDER" .uzd a f(Ac of 5100.00 a day against mc. '1 undcrrt.and that a copy c! :'a(cetcnt r.lay tx fon+ardcd to the Oc of 1nrestirltion o(thc DIA for coyerage Verification., '.' is err ,}• cc/ r ' 1•II (;( nce paint end ptnallirr :..'•:::rc of spplica(ion: T t Nt / (,',v Date: talc'/( 0 Phone:? ( l06 2 -t'vl v (•') not NT,te 1:1 l'JS a :CJ — lo t••: completed by city or t)w..1 is Permit y: 1'• Map #: Lot*: Unit*: Street #: Street Name: Street utt #:.�__- .---_ .v.. ....r..� Permit #: L:Sy --- Department: liva #dln� Document Type: jJan) (Plat) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 -862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work aithorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: ' Lt--Owner of Record: Assessors Map # 67 Lot # 913 New: Renovation: Replacement: on,pfrt Installing Company Name: Company Street Address: �`°` ``�' N� 1ity: Zip: 7/ 4 6 5 - -LeY/ a Company Phone Number: Estimated Cost: $� Indicate total number of units in the applicable box below Type of Occupancy: Plans Submitted: Yes No Basic Building Code Ci ommercial 1 & 2 1V1Fh1y Basement L _ °o N u � °o LL � N L _ °o "' I, M Roof c 0 O 6- Air Handling Units Hydro Air. Unit Draft Inducers Oil fired Equip Evaporative Coolers Kitchen Vent & Exhaust Equipment Heat Pumps Pool Heater Range Hoods Vented to Exterior Process Piping Refrigeration Units Roof Top Units Central Air Conditioners Radiant Heat Ventilation Fans l Energy Recovery Ventilators Furnaces- Oil Central Air Conditioners Generators Other: Other: tit >di1 / -esL ,...--/ Basic Building Code Ci ommercial Basement I o Z. 8 N 'a U- iM Roof"' l o L 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: tit >di1 / -esL ,...--/ y4.-J � Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all Taws /bylaws /regulations of the Town of Lexiag4pa.:. Signature: Print Name: Type of License: C 553`? License #: Permit fee: Issued By : goitARevised 12/31/09 Thi�Se t' f Off l U O l Receipt #: ,7 y,3o? Section or jca Use n l\` Date Received: /0��/3� Received by: l Approved Date: //4%1 Permit Number: ,fixA Map #: Lot #: Unit #: Street#: 4treet Name: Treet Unit #: l Z3 COCf/LTyr J Pc Ca Oepartrnent: din ) t) cuurpent Type: d _t .at) (E QL TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 L TO This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: ( Owner of Record: (u5,f Assessors Map # Lot # Type of Occupancy: New ✓ Renovation: Replacement: Plans Submitted: Yes Installing Company Name: Construction Specialties P.O. Box 53 Company Street Address: Stoneham, MA Q2180ity Zip: Company Phone Number: F7— 6 ""- (-1'1 / C Estimated Cost: $ f Oz3 - Indicate total number of units in the applicable box below 18x2 Family iNi Basement I 6 a u. , O o u- N L a u- M Roof I Ground` Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement 1st Floor oo u. N c °o u_ v M Roof* I Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: /i PL'0(%1 01) CrtlA1 Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Signatur i-1A4 Pr,� Print Name: Type of License: Cs5 -) License #: This Section for Offical Us Only Permit fee: _' , 00 Receipt #: A$S Date Received: 3// Jr + Received by: Issued By : Approved Date: Permit Number: Revised 12/31/09 TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: °] Owner of Record: Assessors Map # Lot # New: ,-Z-Renovation: Re Installing Company Name: �onstrti ©1l "` P.O. Box uc 53 - ..;allies Company Street Address: Stoncham. M.4 ©C210 Zip: Company Phone Number: ) Y-/ - , 5 --Y Y / o - Estimated Cost: $ 79' 5— c Type of Occupancy: Replacement: Plans Submitted: Yes Indicate total number of units in the applicable box below a =asic Buildhig Code ommercia 1&2 Family Basement ° u ° v ° v Roof I c OL Air Handling Units Draft In cers 0i1 fire&Equip Hydro Air Unit Kitchen nt & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Pipin Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioner Hydro Air Systems Ventilation Fans Central Air Condition - rs Energy Recovery Ventilators Other: Furnaces- Oil vvF 3G. t Generators ✓" :r Other: a =asic Buildhig Code ommercia Basement o° o N 0 u. ch Roof" I Ground* Genet- ors Draft In cers 0i1 fire&Equip Kitchen nt & Exhaust Equipment Pool Heater Process Pipin Roof Top Units Radiant Heat Hydro Air Systems Central Air Condition - rs Other: vvF 3G. t ✓" :r Describe Project: *Note: If any eq ►pment is being placed ou ide of the footprint of the building, .ndicate s backs to property line. A land survey may be require Roof top units may requir a Structural Engineer's review. E ipment t t is visible from a public way and within a Historic Distinct will require prior approva of the Historic Districts Commissi . All eq . merit is subject to Lexington's Noise By -Law: a, I certify that I have the authority to make the foregoing application and that all of the information 1 have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws/regulations of the Town of Lexington: Signature: —17 41 F(,Z Print Name: Type of License: cS5 r? License #: This S Section for Offical U e�'' Date Received: 0,;7710 y Permit fee: 4000404. Issued By : Approved Date: 470 tt� Permit Number: to /C .51M (e Revised 12/31/09 Rece. • # Received by: Oc- &JAA me_ . t'zu Wit; Map #: Lot #: Unit #: Street#: 4treet Name: QGt7f 4rt.J�" rreet Unit #: rrni t #: /4' —3-53 =department: 3 u 3lqtn OncInjent Tvpe: ( t .xti (FCc!ip (Perm) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a BuildingPermit FEE: $12 per one thousand valuation or any portion thereof Property Address: di tour4- p tt p!A-C Owner of Record: Assessors Map # (p 1 Lot # 5 Type of Occupancy: OnD New: 7 Renovation: ' Replacement: Plans Submitted: Yes Installing Company Name: 4!1 1cM1 Ai 12 i hvc Company Street Address: 3 D(F`r'u0Or> OK City: 'q�r�Cc vR Zip: off-7 6 Company Phone Number: R e b t f o g$ b Estimated Cost: //, 5-00 Indicate total number of units in the applicable box below Family 'VIE1 & 2 Basement 1 o 2nd Floor I 0o M Roof c Air Handling Units Hydro Air. Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans )C Energy Recovery Ventilators Furnaces - Oil Generators Other: Basic Building Code Commercial Basement 1 o u. P 2nd Floor I 3rd Floor �°o 0 (D Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat, Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to. Lexington's Noise By-Law: 1 certify that I have the authority to make the foregoing application and that all of the information l have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Signature: .P013 6u (( Print Name: Mtr�c 41 Type of License: License #: This Section for Offical Use Only Date Received: 0:40/1:70/0 1 n A Approved Date: Permit Number: Permit fee: /14/: Receipt #: a 7CoZ Revised 12/31/09 Received by: /J _ .6-33 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): /hvi ( i 1 IV r Address: 35- AF`T bD City /State /Zip: ,K_sl; ,k-2--kA #: t D r b90 E-0 � � Are you an employer? Check the appropilatelbox: 1.' I am a employer with 3 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub - contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6.10 New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other *Any applicant that checks box #1 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. Contractors 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. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: (L 5 3i 2-7 al ((QC_ Expiration Date: 3 I 7 (2o / / Job Site Address: 9' 3 I 1 31 if Ovf P-04) P (4( Q City /State /Zip: GQi 1 l 0 %► " l b Z (1Z 0 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 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 certift under the pains and penalties of perjury that the information provided above is true and correct. Date: 00/20/ % Signature: Phone #: '767e— ' g-ggd 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, 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 is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing 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 than 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, §25C(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, §25C(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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(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 Town 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 &home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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 Revised 4 -24 -07 Tel. # 617 - 727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617- 727 -7749 www.mass.gov /dia ACORQ CERTIFICATE OF LIABILITY INSURANCE DATE WM /DO/YYW) ,M 04/26/2010 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PRODUCER (781)665 -1034 FAX (781)662 -0301 Wilson Insurance Agency Inc. 109 West Foster Street Melrose, MA 02176 Keith Bowden INSURED American Air, Inc. 35 Driftwood Drive Tewksbury, MA 01876 COVERAGES INSURERS AFFORDING COVERAGE NAIC # INSUHtR A Travelers Indemnity INSURER H. Travelers INSURERC Ins. Co. state of Pennsylvannia INsuRER D. Ace Property & Casualty INSURER E THE ANY MAY POLICIES. LT rret POLICIES REOUIRLMENT, PERTAIN. OF INSURANCE LISPED BELOW HAVE BEEN ISSUED TO THE INSURED NAME() ABOVE FOH THE POLICY PERIOD INDICATED. NOTWITHSTANDING TERM OR CONDITION OF ANY CONTRACT OR 01 HER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY DE ISSUED OR THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANU CONDITIONS OF SUCH AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBER .�F�r.� POUCV EFTE/,lrvt DATE (MM/O IYYYYI POLICY EXPIRATION DATE (MMIDD/YYYYJ LIMITS A GENERAL X LIABILITY COMMERCIAL t:ENFRAL LIA8ILI I Y ICI AIMS MADE Fri 1 OCCUR 1-680-5840112-9- TM -09 BA- 1867P29 -09 10/25/2009 10/25/2009 10/25/2010 10/25/2010 EACH OCCURRENCE S 1,000,000 UAMAt;L TO REM Ell PREMISES1EA Da:o ence) $ 300 , 000 MEU EXP (Any one pen -An) 3 5 000 PCRSONAL A Any INJURY $ 11000 , 000 GENT. —1 AUTOMOBILE _ X X X GENERAL AGOHtGATT s 2,000,000 AOGRFGATE LIMIT APPI ITS PER: POLICY I ^ I ; CC n I 0f, LIABILITY ANY AUTO ALL OWNED Al ITOS SCHEDULED AU (OS HIRED AUTOS NON•OWNEU AUTOS PRODUCTS COMMON At3C, S 2 , 000, 000 COMOINEOSINGIFLIMIT (Fa scci JanI) y 1,000,000 BODILY INJURY (Par pere0n) t KOUII Y INJURY (f er er,r.4cnu S PROPER I Y DAMAGE (Pet occident) $ GARAGE o.-- LIABILITY ANY AUTO AUTO ONLY • EA ACCIDENT 3 OTHER THAN EA Ace S AUTO ONLY ACE; S EXCESS I UMBRELLA LIABILITY OCCUR CLAIMS MAOC DEDUC I IN RETENTION S CUBW2856909 10/25/2009 10/25/2010 fAr.II000URHENCC 3 1,000,000 AGGREGATE i 3 1,000,000 $ $ C WORKERSCOMPEN9ATION AND EMPLOYERS' ANY PROPRIETUWI'ARTNCR OFFICtiUMF.MDER (Mandatory 11 v0 B, desrrlbe SPECIAL PROVISIONS LIABILITY /EXECU1A/FYI I EXCLUIIFO, - C4 5883127 k., 03/07/2010 03/07/2011 ToRYLIMITS ER El CACHACCIUFNT S 500 000 E.L. UISFASC • EA EMPI OYEE L S00, 00a In NH) wMler 0810w E1.DISt:ASF. POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERAT10N91 LOCATIONS / VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT 19PECIAL PROVI910N$ CERTIFICATE HOLDER CANCELLATION AMERICAN AIR, INC ACORD 25 (2009/01) SHOULO ANY OF THE ABOVE DESCRIBED POLICIES DE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL OATS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 30 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY RIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Keith Bowden ©1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD JitxA 7/bet- \YAL-d-J Map #: • Lot #: Unit #: Street #: street Name: Treet Unit #: 9 �O6(T /4A1) F Department: 3 «3lJing, Document Type: (PE-) (Plot) ('Ferro) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address : * ice, -6" Owner of Record: Assessors Map # Lot # ( 6 Type of Occupancy: ODODO New: Renovation: Replacement: Plans Submitted: Yes No ✓�- Installing Company Name: ,12 (CI J He we. Company Street Address: 3 5- D 1P-A T WOOD ity:RkMrSV) \{k Zip: Q (g 7 to Company Phone Number: tg d Estim ted Cost: $ b °' Indicate total number of units in the applicable box below 11W1&2 Family Basement 00 $' N 3`d Floor 1 Roof Ground* Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit KitcherrVent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces - Oil Generators Other: Basic Building Code Commercial Basement 1st Floor I o LL N 3r Floor Roof* Ground* Generators Draft Inducers Oil fired Equip KitcherrVent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By-Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws/regulations of the Town of Lexington: ignature Print Name: Type of License: License #: This Section for Offical Use Only Permit fee: /WO,- id %00/0 Receipt #: a1(,h. , Date Received C .J Approved Date iu /a No Permit Number: / J3 r / Received by: J,A. 10,e_ ‘,/,--e4 fiLEt N,Y4'<-4_/ A-d-/ Map #: Lot #: Unit #: Street #: street Name: Treet Unlit #: '<',rffiit #: 6 Department: Bualdin /'` — 8' e/ Document Type: (P) (Piot erma TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a BuildingPermit FEE: $12 per one thousand valuation or any portion thereof Property Address: Assessors Map # Lot # ett3;,e—ner of Record: Type of Occupancy: New renovation: Replacement: Plans Submitted: Yes Installing Company Name: Consuuction Specialties Company Street Address: P.C. toeh . t Stoneham. MA C121� y: Zip: Estimated Cost: $ '7? Company Phone Number: 7 77.-676 -�-G '/ c.) Indicate total number of units in the applicable box below family A/1 1 &2 Basement I ° N , v_ � nJ S u_ Ti ch Roof I Ground* Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement o 1.1. ) '— 0 U- cJ 0 u ' c Roof* Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: t1VF-36 • h11P'2 Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information t have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all Taws /bylaws /regulations of the Town of Le • oton: Signature: ( Pr,UAc) Print Name: Type of License: (.5 5 3? -) License #: Permit fee: g0,00 This Section for Offical U e O ly Date Received: S 7 /'I Receipt #: A937 Issued By : Revised 12/31/09 WW1. Received by: Approved Date: *(0 Permit Number: 10 �<3 r;) r4mc: 1.c-72tion of woft rit: t, ll'asAIngfon Sir rc I "°‘'I • "ra-.ConIpcto$1.17:on,h)tVeyvIcc • COnStrUCtidlitNigei0e8II(r 14Cfrit'Y • P.O. Box 53 1>honc *-7? 66 o 1 arts hooleolvocr perfortuint all work mysclf. , .'•': • I r:t so!: pro:nit:tor *:•d have no one Viking in any capacity. I am in cmploycr providinc IsotS;crs' compUo n for my cr.iployecz. workine on this Company namc: (";:::;•.1:'.y ary: Policy: ins..:tan:c Company: r Phonc I am so!: proprietor, general contractor, or hortico%vncr (circic onc) tr.d kivc hircd 01: Corttro:::ers t:;:to',v who JL1VC the follossinc workcrs' compOnsation policy: Co tilp•any name: addrests: Company .......■■••■■■■■••■ city: Phone Statc: • c02,r,any tuniv Construction Specialties •• a StOnetlf.MLIW8.. 02180 Company: ./UAT‘L U411 04) F1 gr--poi;: oc)6, - 7 • 9)5- 3 Pltonc 2 07 ce Li I (3 IA)S... C-0 ,•• •A.;ta•th a:1...ttiortal shots if necczsary. - 4ti( 8--:( 7? 1 ( 0 FaiLtIrc to secure cove as required under Section 2M of' MCI...152 can load to the implcmentation of 4 1P...11 penalties of a finc up to S.1,500.CO and / or one ycari' imprisonment as Ise!! as civil pcnaltics in tL,: form 2. "STOP WORK ORDE.R" .aA.1 a fit of SI00.00 a day ataing mc. .I understand that a copy of ;h..; statement r.uy be fonvardcd to thc OflicC of Investigation of thc DIA for coverage vcrific-ation, .' !,y cc, V), wriziey. rhe /N71,-; and peno It: ( J r..urc ef pplication: 1)t: 5/)( C) T /vAo w 0 •■• • • . : • 0:1!)." not mite in this arca - to b.: complcteJ by city cr town ofne.ia! • pcnr.:•( pfit °"(- dje4 /1A 9e6,4fra Map #: L/ / Lot #: bj Unit #: Street #: f street Name: C,UC,e/';Y' ',4912-6� T,eet Unit#: mlt #: /0 535- Oepartrnent: Bu iding Onemnent Type: (P ban) (Plot erm) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit" FEE: $12 per one thousand 'valuation or any portion thereof Property Address: 33 CO V (Lt mai> ' IC Owner of Record: Assessors Map # /Lot # 9/3 Type of Occupancy: New: Renovation: Now Replacem t: Plans Submitted: Yes Installing Company Name: 4 e te44.0 P-1 N C Company Street Address: 351t1 C-11/430 A— City: uj cst vie Company Phone Number: q 7 e 6 L{0 o g g d Estimated Cost: $ _ 6` Indicate total number of units in the applicab 1JW1&2 Family Basement I 0 ,, o 0 `o 0 v_ Roof * 3 I?_ Air Handling Units Draft inducers Oil fired Equip Hydro Air: Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans ' x Central Air Conditioners Energy Recovery Ventilators Other: Furnaces - Oil Generators Other: e box below Basic Building Code Commercial Basement I a u.. o u. N o u. co S 0 o Generators Draft inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Rooftop units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By-Law: I certify that 1 have the authority to make the foregoing application and that all of the information l have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of xr g ' n: ignature: rint Name: EMI"— Ottectis s\oQf- MAC '-7 3 License #: Type of License: Permit fee: %9 Receipt #:a This Section for Offical Use Qnly wit► Date Received: bho Revised 12/31/09 2.0 Received by: ved Date: f% ermit Number:, _ 3 JiticA /Jar_ aele-4 Map #: Lot #: Unit #: Street#: 'treet Name: C'®aYD : ;Treet Unit #: '„rml t #: !Department: tl n I) raiment Type: dt tzn) (p'lnt Perm_ TOWN OF LEXINGTON APPLICATION FOR MECHANICAL' PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 3q (;OU1 r(,' Owner of Record: Assessors Map # Lot # (9 l 13 Type of Occupancy: tee, New: (' Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: OVOW fki 1 ArC Company Street Address: 35-- De f JI) p(City: VAIratigy p: j jr Company Phone Number: q 7e .S 9 Estimated Cost: $ Indicate total number of units in the applicable box below 1 &2 Family c w 0) (0 CO ` 0 O 0 0 LL fV 0 0 u- v a 0 c 2 i ! ',1:hyJ AT_ d-te-4 zibe-t. fiLe_eze_ ?, j,e, Map #: ✓ + Lot #: Unit #: Street #: street Name: ti'Gc° L7 '' // / ij - ;Treet Unit #: �rmit4: }department: JElthciing 00e1 tnient Type d _AL.ItL1 ) Fe %6]lL TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 3L( Cent. ,/' eidafier of Record: Assessor Map # / Lot # 916 Type of Occupancy: New: Renovation: Replacement: Plans Submitted: Yes Installing Company Name: Constr ' _ r kallies Company Street Address '•O. Ec; L: City: Zip: MA 02183 y� p: Company Phone Number: %$ ( — & S` - 14(4 1 0 Estimated Cost: $ .$-)9 S Indicate total number of units in the applicable box below 1 & 2 Family .1‘ ir Basement _o° u.. °o Li 2 N °o L.L. a ce) Roof I c z U` Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement o 0 u- C N 3`d Floor Roof Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other:'l 5 Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Signature: (.t 4) Print Name: Type of License: CS54 7 License #: Permit fee: Issued By : Revised 12/31/09 Receipt #:,,,7 This Section for Offical Use Only Date Received: //AV/4) Received by: Cki Approved Dat,09 1 Permit Number: `0 jjxyj idar, die-4 NYAL-d- A-d/ Map #: 6 / Lot #: Unit #: Street ##: itreet Name: =rreet Unnt #• }department: Buthding; Dn1 !ment Type: a! t at) tFtot) (Perm) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: Assessors Map # Lot # Type of Occupancy: New: Renovation: Replacement: Plans Submitted: Yes No e °-Owner of Record: Installing Company Name ?r o n toy .. ►,6 Company Street Add>o;t 53 City: Zip: en gaxrn. MA X 21 S3 Company Phone Number: D ij f 6, c - ‘-( • Estimated Cost: $''� Indicate total number of units in the applicable box below Basic Building Code Commercial 1&2 Family Basement a. 2nd Floor 3rd Floor Roof C Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators . Other: Furnaces- Oil F Generators C1/4"D Other: Basic Building Code Commercial Basement o L.L. U .-- 0 u.. € N 0 u- cr) Roof* I Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: F C1/4"D Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all Taws /bylaws /regulations of the Town of Lexington: Signature: Print Name: Type of License: License #: Permit fee: Issued B This Section for Offical Use my �jo,bReceived by: 4.) Receip #;� �} Date Received: Revised 12/31/09 Approve e: 7/o Permit Number: 0.7 /..x, idle- been ,te,t Map #: 6 Lot #: 6' 9 ig Unit #: Street#: 'treet Name: Ou/zi )2D PLC ;J;eet Unit #: 'ermit #: 3 6, Department: B EtiIdin 1)N -urgent Type: (Pi . 2 ) (Plot 10--/ �.5 2 (Perm! RN TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781-862-0500 x -211 Fax: 781 -861 -2784 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: &Ply oft fr(&wner of Record: Assessors Map # ( ( Lot # rr(1 Type of Occupancy: New: Renovation: Replacement: Plans Submitted: Yes Installing Company Name: COW l R I/1iC Company Street Address: i % : retli /LS o/ Company Phone Number: 7 7 6 Va g Indicate total number of units in the applicable box below Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners, Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: 0 E m: 0` 0 L `0 0 LL 0 0 LL cc) o; 0 c z 0 Basic Building Code Commercial Basement o ii: r L.• u- N o M Roof c 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I- certify that 1 have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachus tts St.te Bui•i , ode, the International Mechanical Code, and all laws/bylaws/regulations of the Town of L Permit fee: 1 ,00.Od Issued By : .044 This Section for Offical Us nl Date Received: ((b7ro Approved Date: (, /�' Receipt #: '3-777 Received by: % Permit Number: ID ■ J,It/LA c c� i-/-e-4 Map #: 6 Lott 6 Unit #: Street#: 3 % street Name: 6106(-AD PL,q- rreet Unit #• °-- /.<310 #department: Buit(j iIneitt?leni Type,: (Ptzn) ! aw Term) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 ENTERED SEP i This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: j t of Record: Assessors Map # 6/ Lot # G 9r New: Renovation: Replacement: Installing Company Nart�o�,* Type of Occupancy: Plans Submitted: Yes No 9claltle Company Street Address �; City: Zip: Company Phone Number: (— (o 6 S - �-(� l D Estimated Cost: $ 7 �` Indicate total number of units in the applicable box below Basic Budding Code Commercial 1 &2 Family Basement o 2nd Floor 3rd Floor Roof Ground* Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: Basic Budding Code Commercial Basement S u- T- o u- N 3rd Floor Roof` I Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Sign ture: L Print Name: Type of License: License #: Permit fee: '30 Issued Revised 12/31/0 9 This Section for Offical Us Onl Receipt #: tVk Z Date Received: 9 /7 Approved D e• Received by: Permit Number: � a2o� �.�eva �nE� fiueet. A( Map #: I Lot #: 6 l'l •CJ Unlit Street#: •treet Name: &6:01Z7 /.4-' J PZ— ;Treet Unit #: 3 Department: 3IRdam, ��a1� Rtrnent Tvpe: _(F [zR,tt !Floc TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781-861-2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 3 b COJy! It Owner of Record: Type of Occupancy: Assessors Map #_ "Lot # New: Renovation: Replacement: Installing Company Name: 1i C Company Street Address: 3 Ur (F Company Phone Number: q la 6 (O goo Zip: le 2,6 Estimated Cost: $ '9' Q 60 Indicate total number of units in the applicable box below 1 &2 Family m 0 4 0 0 LL 0 0 u- C) 0 0 c 2 0 Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic. Building Code Commercial 0 a0i 0 (6 m 0 u, 0 u- a N o u- -a co Roof g o 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information 1 have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application'wil be in compliance with all pertinent provisions of the M. sachu etts State Bu`. � �' • Code the International Mecha ical Code, and all laws /.ylaws /regulations of the Town of L; n. on: ..,., 1 / ► 1-f I � ' #4 Permit fee: 6- Issued By : Receipt upf-t of License: This Section for Offical pnly Date Received: (l /10 proved Date: , t J /v 3 Liven - Revised 12/31/09 7/< Map #: Lot #: Unit #: Street #: 3 street Name: //94�,E ;T eet Unit #• _ 'grant#: /CJ /32 Oepartment: Bi' J dmng Document Tvpe:, (Pt n) (Plot) (Feria TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781-862-0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property (ddress: C,e-a ettlyf Record: Assesso s Map # fe r Lot # fp 9 Type of Occupancy: New: Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: onstruction Specialties Company Street Addre.D. Box 53 City: Zip: ,c, wham. 0 g Company Phone Number: 7 /j k - L 1/ 4) Estimated Cost: $1 Indicate total number of units in the applicable box below Basic Building Code Commercial 1 & 2 Family Basement I V _o , w L °o v u L °o � . Roof c 2 O Air Handling Units Draft Inducers Oil fired Equip Hydro Air. Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators C, P Other: Basic Building Code Commercial E c, (4 m $ N — oo U- -0 N ° o U_ D M Roof* „puno.lo Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: C, P Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: 1 certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexin tg_oz Signature: 747.4 F-7.1',,% Print Name: Type of License: License #: This Section for Office' Use Only Permit fee:361, Receipt #: v2 a Date Received: ////41/D Received by: proved Date: ////7//o Permit Number: Issued By : Revised 12/31/09 /D 43ci7e • , GEC? l i txali /n j•(Jn Sire ; )1'w 44" fa',COnt's(I)J•dfall•/nrvrrvrco,Q",•1dm•!1 PConstructidriP 766i ' eT 11'GIDI,1' .O. Box 53 ,— ) !'hone 1.c•-ition cf wvtL rit:: 1 a::r homeowner per forminc all yorfc•mysclf. 1 a':r sol: proprietor and no one workinc in any Capacity. c;:iploycr prv,idine liorkcrs' cornl>;ruation for my c.rsplo)tu wog kinc on tl�s .:.�. C'a a: •any ramc; 6GS -ctki<o Phone Coniruny: Policy: proprictor, general contractor, or h9ntcowncr (circle onc) and love farad t!s- coat. 'at,rs 1:;::,!1.-:!ow who hive the folloinc Korkcrs' compdnsation polity: C'o -any rune: ai;.rrts: 4 Company Cc !r•.iry rim:: Construction Specialties ! s Stoneham. M 021 ,..!:e amp N 80 city Stoic - -- c Cor::pany: /12. L VN� c)L) lRF rorry: R.J C„_ A't:]c' ��' Cort! shc<ls if nccusary, / /U�'_ GO -' '5i( ,i!'• c to s:curt coverage IS rtquircd under Scction 2$A of -152 can 'cad to the implc c ; i m.n anon cl a r• :rultics of a tint up to 51,500.00 and / or onc ycari' imprisonment as ucli as civil rrni!tics in forty i -STOP WORK ORDER" .and a flit of 5100.00 a day aeainsl mc. •I undcrstamd Doc a copy cf t! :s s' �tcmcnt ruy tx fon,arzrrcd lo the OtTcc o(Invc$titatlon of the DIA feu coverage verification, i; „r'. }' ccrrifj' a'rrd& !!re pa!nf end penallirl c( application: Uatc: Policy: phone Suet: _ Plwnc 7°7- 66 5- - Le Lt C� PhoncT) I ( c"{fY/ C� O :•'):" ;'] not 1%TIlc t :1 t!Jt a:c] — to 1'•' complete by city cr c.ir, ^ :1i Pcn::it 1: 'J.,1u(A if-e4 fiLe_ezi_ Map #: Lot #: Unit #: Street#: 'treet Narne: 6'o ;greet Unit #: ',trait #: /0 —./03 Oepartment: 3uiici t)oeifinent Tvne: _(1±.n) iblot iperm TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 - 862 -0500 x -211 Fax: 781- 861 -2780 ENTERJ s P1 This Application shall only be used if the work aithorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 3 of Record: Assessors Map # / Lot # 69P New: Renovation: Replacement: Installing Company Nan on' Type of Occupancy: Plans Submitted: Yes No Company Street Addresz c.`���� "�� 02180 City: Company Phone Number: f b6->c D Estimated Cost: $ Indicate total number of units in the applicable box below Basic Building Code Commercial 1 & 2 Family Basement 1 00 u_ `— 00 LT. N 00 `` 'co o ��0y c (.9 Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil iv F �r pip Generators L/ Other: Basic Building Code Commercial Basement 8 0 LL" r- `o 0 u- N 0 O") w- o ° 0 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: iv F �r pip L/ Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Signature: 77M F<N/41 Print Name: Type of License: License #: Issued By • This Section for Offical Use my Recei t : dc4/ 7 I Date Received: /7 I Received by: ,<J 7/v/0�� 7 Permit Numbe Revised 12/31/09 Approved Dater J,4A die4 7itet Map #: Lot #: lj % 19 Unit #: Street#: street Name:�'/�T% =reet Unit #• 'ermit #: /Q Oepartment: Building Document 1!ment Type: (Ply. =z} ("Pio lFerl TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -21 I Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: of Record: Lot # 69.B Type of Occupancy: Assessors Map # New: Renovation: Replacement: Plans Submitted: Yes Installing Company Na nstriir tk, Company Street Address- No 1E0 City: Company Phone Number: ) �% b b — Y! Zip: Estimated Cost: $ r Indicate total number of units in the applicable box below Basic Building Code Commercial 1 & 2 Family Basement 00 " `." L 00 u- N L _00 " c0 0 �N0/ Y c 0 Air Handling Units Draft Inducers Oil fired Equip • Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil 1® Gr.' 97jz A 2+_ & Generators l Other: Basic Building Code Commercial Basement I 8 ,1. 7, r' 8 u- N 0 L.T. v co o x 0 09 O 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: 1® Gr.' 97jz A 2+_ & l Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all Taws /bylaws /regulations of the Town of Lexington: Si natur / (A4 ice( AI AJ Print Name: 55 3 -7 2 Type of License: License #: Issued By : This Section for Offical Use Onl Receipt #: ,27e) I Date Received: �� `� Received by: f�Approved Date: Permit Number: Revised 12/31/09 • ..,'*:..o..NolonVitilOilj COQ )1'manIng(un Strr (I Wolf Alr on..niutrante,Q;;;!.."qi COrlStrUCtidr) 11.• 'LUNT 11.101131. rarne: P.O. Box 53 es Phonc 4.-771-66 o 1,„ pc, lorminz L4 ■volicnlysclf. proprietor and it.31V no 0(C yrkinc in any capacity. I e::: c;:tploycr pruvidinz IsNotkcrs' 6ocitiv.ruation rot my cmployecz Ivor kin on 0:is Con:pany namc: 4 Phone 1.1.!fc:s: CIty: Cony' Policy: 1 aril s.)!: proprietor, ccncral contractor, or hqnscowncr (circic onc) and have hired 01: con!r3.:tcrs L.dow who havc the rollowinc workcrs' comp4.n.sati0 n Corttarty narnc: Phone address: Company: Policy: Statc• cc y Raml: Construction Specialties Phone 2 66 --"P:XX130x53--- ,,,..,.:, Stoneham. MA 02180 - cit), q l us c_o , 3,...t.itjortal shctls it ncecssary. .: 1, _ s to s,:cure coverage aS required under Section 25A ofl.IPL.152 can lcad to thc implemensation or 4 c:::::ir_11 pzaillies or i [Inc up to S'1,500.00 and / or onc ycaril imprisonment as wcIl as civil pr.naltics in . c.: form a 'STOP WORK ORDER" LAJ 1 fwe of S100• 00 a dai atairtg mc. .1 undcrstand Liu( a Copy of . nuy tn forwarded to thc OfricCof Invc.stication of thc DIA ktt Coyc race vcrific-atioru ..,,, i:,,-c.'')• cc/10,1.7)4kt Ike pain; end pentillic: Cr ipplinGon: D31C: c---`-( ( 0:•.!)*^ ttOl Wri1C i:1 t 1:Ca - 1) 1.: COMptC1CJ by city Cr l):■11C1:7::1! , • . Pcrtnit It• • . • . JI-4A Map #: Lot #: Unit #: Street#: street Name: 'reet Unit #: ¢)epartment: ()c 1!rnent Tvpe: dF(z.xtt (F!c?L (Perris TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PE T 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 2 CCWer Fii v, 'eat Owner of Record: Assessors Map #o29 Lot # /5-- Type of Occupancy: p ,C Psis cQ, New: Renovation: Replacement: >C Plans Submitted: Yes No X Installing Company Name: C2 v oA Cra j ,•,,,� -F A Pa l ii j , 2 C Company Street Address: 9 y m, JP S City: 1,JObtjr„ Zip: eiia/ Company Phone Number: 7fi Estimated Cost: $ /g,. Indicate total number of units in the applicable box below Basic Building Code Commercial 1 & 2 Family Basement L _oo r' L o° Li- N 3rd Floor Roof f Ground* Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps .. .. 1111 El Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: F ,....r,, cj r,, cace — aS Basic Building Code Commercial Basement cool% is I, 2nd Floor 3rd Floor I Roof* o C = 0 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may besequired. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: cia I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installatio . _ .erformed under the permit issued for this application will be in compliance with all pertinent provisions of the assach s : is Sta - Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of xip Sig ature: mICNAgI QlkAfkie4 Print Name: Pe fee:4 ) Issued By : Revised 12/31/09 ry ts-s f'- Type of License: This Section for Offical Use Only Receipt #a 77/3 Date Received: 0/29N Approved Date; cc-137M License #: Received by: e Permit Number: The Conntonwealth of Massachusetts Department of Industrial Accidents' O ffi c e qf Investigations 660 Washington Street Boston, MA 023 wviw.ntass,gov/dia Workers Compensation lngurance Affidavit: Builders/Contractors/Electricians/Plumbers cant Information. Nine (Business/Organization/Individual): !, t,-; C r f Map # # Address: Per mit A. (idea': q t\j jt Cityff'Aale/Zip: Are you n employer? Check the appropriate box: 1. 1 I am a employer with 4. fi I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 2. 0 I am a sole proprietor or partner- listed on the attached sheet. P. none 4: -7 c ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub-contractors have employees and have workers' comp. insurance.I 5. 0 We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. D New construction 7. 0 Remodeling 8. fj Demolition 9. D Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.2 Other fzo, (ae-e *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. IContractors 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. 1 am an employer that is providing workers' compensation insurance or my employees. Below the policy and job site information. Insurance Company Name: C.-- L' Di IN) 5-U,K C Policy # or Self-ins. Lie. 77) = (.7 5 6 Job Site Address: 2 CI-4+- Fos'AN. Expiration Date: City/State/Zip: tach 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 ofl■IGL c. 152 can lead to the imposition of criminal penalties of a fine up 10 S1,500.00 andlor 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 under the pains and penalties of perjury that the information provided above is true and correct Phone #: - 33 - Date: / 124, 7 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Infor tkn and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers.' compensation for their employees. Pursuant to this stiitute, all employee is defined as "-„„every person h the service of another under any contract of him, express o; implied, oral or WrittelL" An employe, is defined as "an individual, parniership, association, corporation OT other legal entity, or any two or mole of the foregoing engaged in a koint 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 ofa dwelling house- having not more than thtee apartments and whc resides therein, or the occupant of the dwelling house of apothei who employs persons io do maintenance, constractioii 'epai' work on such dwelling boom 03' on the gr oimdF or building appurtenani thei eto shall not because of such employment be deemed 10 be an employer:' MC.ih, chapter. 352, §25C(6) also sates Thai "every sate o cai licensing age tie:. she: withhold the issvaracc. @i- 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., §25C(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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(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 e Iiisloyees, 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 ;eIfinsmance license number on the appropriate line. City or Town 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 sun to fill in the permit/license number \Villa will be used as a reference number. in addition, an applicant that must submit multiple permit/iieense applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Yob 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 cr 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 home owner 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 Invesfigations would like to thank you in ad.van.ce for your cooperation and should you have any questions, lease do not hesitate to give us a call, The Department's address, telephone and fax number: The Conamortwealth of Massachusetts Department of Industial Accidents Office of Investigations 600 Washington Street Boston, /vfA 02111 Tel. # 6 7-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 wwwmass.govidia Revised 11.22 -O6 COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE BOARD OF IN PLUMBERS AND GASFITTERS LICENIApEABNM-AN PLUMBER MICHAEL C BERNASCONI 58 ALBATROSS RD QUINCY MA 02169 -2658 • 1 1 LICENSE NO, :' EXPIRATION DATE SERIAL NO COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE- BOARD OF IN PLUMBERS AND GASFITTERS LICE ? rksAjyykamircFLUMBER MICHAEL C BERNASCONI 58 ALBATROSS RD QUINCY LIC SE N4O MA 02169 -2658 1 EXPIRATION D " ER Na! COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE BOARD OF BOARD OF SHEET METAL WORKERS AS A MASTER - UNRESTRICTED ISSUES THE ABOVE LICENSE TO: MICHAEL C BERNASCONI K• 58 ALBATROSS RD QUINCY MA 02169 -2658 773627 ICENSE NO EXPIRATIONDAT SERIAI .,7,/,(A d/-e-4 Map #: Lot #: J Unit #: Street #:j street Name: Di1/1/ 7,E6. ;reet Unit #: i n31 t #: /D Oepartment: Building Document Type: 4iL Z r�i ) 4PE17...Term TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit r'EE: $12 per one thousand valuation or any portion thereof Property Address: 8 ,4,/y) ' 1 t 5 Owner of Record: AVon)/ Assessors Map # 3 Lot # Type of Occupancy: , o f ' New: Renovation: Replacement: Plans Submitted:. Yes No Installing Company NameCNQJ- , s � � ;' c' 1 e Company Street Address: 77J ', iier -a.qt City: CI20 64, cf /€41 dr Zip: a / }� Company Phone Number: 7 7 - � � ' Estimated Cost: o a Indicate total number of units in the applicable box below c a> a) N f6 ce 0 0 0 0 LL N `0 0 o. 0 c 0 Air Handling Uni; Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic. Building Code Commercial Basement S.- u_ N g u C N' o L.L. D M Roof 0 B - %.. '. 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof, Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: 44s i41SO/2 yli'sr Atve ', L G 3 .r v /" 7 P Describe Project: "Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may, be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington' Noise By -Law: t Vag Av I certify that 1 have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regula ' n oJ4 a Town of Lexington: • L i C� U i 54 °-n O.4iSSfe' ��{� _L- is Print Name: Type of License: License #: gn . ture: Permit fee: 3 Issued By : I Rece This Section for Offical Usp Oily (1 — J / 5 ( I Date Received: 6 C$ /0 I Received by: Fk pproved Date: fitrho Permit Number: (0 Revised 12/31 /09 herb //ZZ eatt_ Map #: Lot #: Unit #: Street #: Street Name: Street t:,ritt : �— Permo#; Department; Buitidinz Document Typo: (Pan) (PiOt) ( } TOWN OF LEXINGTON 1v Community Development 2 y Building Division ; V Building Zek,ry ' MOp ins ii 411' A,p ,Sn� tiQ c _ D =4 ; .C" The Commonwealth of Massachusetts State Board of Regulations and Standards Massachusetts State Building Code For One- and Two - Family Dwellings 7th Edition APPLICATION FOR: ROOFING, SIDING, WINDOWS, DOORS SITE INFORMATION: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Permit # / -/3// Date issued: ///7/ Work approved by: / Property Address: Jr Oa Vii cd Q G Expiration Date 12/18/2011 Historic District: Yes / No Assessors Map /Parcel # /5 Y 0 A Registered Home Improvement Contractor: Company Name: Provide name of Waste /Rubbish hauler All State Waste Address: 67 Perkins Ave. Brockton, MA 02302 Is this hauler currently permitted through the Health Department? Yes Phone # 1- 888 -559 -0909 Roofing 5900: (Note: Roofmg is not permitted over more than one (1) existing layer. If two layers of roofing exist, then roof must be stripped before re- roofing.) Roofing shall be installed according to manufacturing recommendations. Proposed work: Strip and re -roof Re -roof over existing single course Number of squares Location on roof Does this involve replacement of sheathing? Yes/No Number of existing layers of roofing? Siding 5700: (Note: Electrical Permit required with application) Proposed work: Strip & re -side Re -side over existing Existing material: Proposed material: Electrical Permit: Yes/No Door Replacement: (Note: Maximum U .44) Number of replacement doors: 3 Estimated cost of work and material excluding electrical cost: PROPERTY OWNERSHIP /AUTHORIZED AGENT: Owner of Record: Name (printed) Lexington Housing Authority Mailing Address: 1 Countryside Village Lexington, MA 02420 Signature Phone # 781- 861 -0900 Authorized Agent: Name (prin ed):' Signature: ilN. Phone # 781 - 861 -0900 Mailing Address: 1 Countryside Village Lexington, MA 02420 CONSTRUCTION RVICES: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Not Applicable: License Number 76563 Expiration Date 12/18/2011 Address: 86 Bedford St. Lake ille MA 02347 Signature: Phone # 508 -583 -3999 Registered Home Improvement Contractor: Company Name: Not Applicable X Registration Number Address: Expiration Date Si mature: Phone # Received by /date: ///j4 Fee: / Receipt #: 029420 Issued By: ..frActAirezadat „.1://(A idal,e_ Map #: Lot #: Unit #: Street#: ,street Name: ::greet Unit #• 7 department: f��n Document Type: (t 12LIPJI PJLA D TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? Property Address: Assessors Ma # New: Renovation: Installing Company Name: Company Street Address: Company Phone Number: . //) J Lot # Type of Occupancy: Replacement: / Subm tted: Yes No ,vi /7-re l'-. City: /74 ell Zip: d/,9)0 Estimated Cost: $ /00a' NO Owner of Record: 7 ?/ 7t ‘2 Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement 0 LL 6 0 LL 2 N 0 LL 2 01 Roof Ground* Air Handling /Hydro Units Draft Inducers Oil fired Equip Evaporative & Refrigeration Coolers Kitchen Vent & Eaust Equipment Heat Pumps Pool Heater Range Hoods Vented to Exterior Process Piping Central Air Conditioners Roof Top Units Combustion Air Nentilation Fans Radiant Heat Energy Recovery Ventilators Hydro Air Systems Furnaces- Oil ■ Central Air Conditioners Other: /digliergrA %C.lv Other: Basic Building Code Commercial Basement o 11 N o o C N LL V M Roof" o 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Eaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I ha application is performed Buildin Insur the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations iss 1 for this application will be in compliance with all pertinent provisions of the Massachusetts State Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Workers' Compensation d for all mechanical submissions Print N t M e: Type of Licens Li nse #: Permit fee: Issued By : solrA Revised 8/4/10 AC Receipt #: This Section for Offical Use Only Date Received: 7/) roved Date: C4 Received by: pite Permit or Alteration Number: jyt, '� �/20 d,a4 /4r t. heed- /a �t- Map #: - 2 Lott j Unit t Street#: 'treet Name: Oekl e ;greet Unit #: Oepartment: Building t) wuumnent Type: j1-101_1021) (Perm) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 -862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 2 t la e u> e y ('e ce Owner of Record: Co r 1 i,e„ r A +c ou e*' Assessors Map # ? Lot # S C New: t/ Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: ji i , T. A ,r ifi`s-,•, 1.111 Company Street Address: (1 l4 r 1 vi if ayl S'7° City: O rc c c., :r Company Phone Number: cl 7 R 7 Type of Occupancy: Reg; el e4 ,1, l Zip: 6 is-2.4 Estimated Cost: $ 1 , 0 o 0 Indicate total number of units in the applicable box below 1 &2 Family E t4 0 0 0 u- N L a 0 LL 0 0 .a- c z 2 C9 Air Handling Units Hyd Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement ao01d Isl. o u- v iv 3`d Floor Roof' z Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Signature: Print Name: Type of License: License #: Permit fee: i -i' . OD Receipt #: Issued By : Revised 12/31/09 This Section for Offical Use Qnly ro Approved Date: 240 Permit Number: 1 a ��a I Date Received: 7 Received by: LEI Are yo an employer? Check th ppropriate box: 1. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information /'? Please Print Legibly Name ( Business /Organization/Individual): J' wft -r44 4, 4 71,"r ae -trdit ikj" ` "n C Address: / 7 ,4r 1, 4570" sT. City /State /Zip: D,- c4,1 1 i* OIf7.G Phone #: g 7 Y g-f"S/ 9 7 Are a employer with , 56 4. LJ I am a general contractor and I employees (full and/or part- time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub - contractors listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.# 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. J Plumbing repairs or additions 12.❑ Roof repairs 13.0 Other *My applicant that checks box #1 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 Contractors 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: Policy # or Self -ins. Lic. #: Crreepl- sW shred WCtagt1P9O7-0.3. Expiration Date: a t r✓ Job Site Address: al oe W C'. y R o u 1 City /State /Zip: L'€$4 1451-o f 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 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 d• , against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of DIA for insurance coverage verification. I do here„ Sig �' : Phone #: '! ie ov � ior aloes off, 'duly that the information provided above is true and correct. Date: 7– Z6' ..—/ 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Map #: 7 Lot #: Unit #: Street#: street Name: =reet Unit #: ''°rmit 4: ,._ 3 C� Oepartment:3��31ciin#� Document Type: (Nail) (Plot; TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -21 I Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address 3S beicied2 1 d Owner of Record:2eX' Assessors Map # 7, Lot # �O S Type of Occupancy: S.rf ri/ New: Renovation: 2 Replacement: Plans Submitted: Yes )r No Installing Company Name:1 iice/a t) / -7rr %vC /~4c- L p o g.x e 39,E Company Street Address: .„e-/ ���, o,.. sit- City: 7c,fricc ,) Zip: 0(7 `fZ esw Estimated Cost: $ 74 Company Phone Number: ) (o cad Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement 1st Floor I. 2nd Floor `o 0) Roof Ground* Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners ,[ Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other c-r//1/4 ces ,P Basic Building Code Commercial Basement o U- r o LT N 3rd Floor 0 o o Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws/regulations of the Town of L- , gton: gnature: /?f 5 (c,,tie>iy'f/rfa /// 0/7 Y((90/ Print Name: Type of License: License #: Permit fee: To•1orr Rv • This Section for Offical Use Only Receipt #" Date Received: 9-7 Received by: z,K, .y A rAnrnt,nhl rota- pnrrnit ATmmlvr- Map #: 7 e Lot #: Unit #: Street #: street Name: 6 3 Treet Unit #: rnl l t #: Oepartrnent: Buildin IDZcatment Tvpe: {I✓ Lin_ (F!r!i) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: Bs ,tom / 7- Owner of Record: r"."7,7,-7-02. G Assessors Map # 7 "Lot # Type of Occupancy:. New: Renovation: k Replacement: Plans Submitted: Yes Installing Company Name: Company Street Address: Company Phone Number: A )2 4 4/ off .% tj/s Zip: 2j3 Estimated Cost: $,%7 Indicate total number of units in the applicable box below Air Handling lslnits Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners, Ventilation Fans 0 ,!) m' 0 0 ^LL 0 0 N O 0 co O O Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement 1 o u m <- $ u- N .100id g 00 D! c, Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By- Law: I certify that 1 have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the a s . e appl'cati • true and accurate to the best of my knowledge, information and belief, and that all mechanical work and ' tall . tio' a • rme under the permit issued for this application will be in compliance with all pertinent provisions of the M . sachu . ' s ` -te Buil % ing Code, the International Mechanical Code, and all laws /bylaws/regulations of the Town of xingto t Name: Permit fee: .-A L, 9-- type of License: License #: This Section for Offical Use Only Receipt #2jiZ Date Received: g--'02t./—m Received by: 0W,17.1 4 Revised 12 /31/09 C^� n Approved Date: Permit Number: ciAdl. �„y(,o+� c 0 The Commonwealth of Department of Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (Business /Organization/Individual) 71/sZJrre7.4.../— Address: City /State /Zip: Phone #: Are ou an employer? Check the appropriate box: wy 1I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub - contractors have employees and have workers' comp. insurance.* 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7.'Remodeling 8. 0 Demolition 9. E Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13. Other '.�i *Any applicant that checks box #1 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. L I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City /State /Zip: 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 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 - : for ins u cove • veri ation. e information provided above is true and correct. at _ f/ Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Permit/License # Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defmed as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defmed as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing 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 than 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, §25C(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, §25C(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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(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 Town 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 home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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 Tel. Revised 4 -24 -07 617 - 727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617- 727 -7749 www.mass.govidia Jitx.A ,(4,-e-4 NY/c-d-i Map #: Lot #: Unit #: Street #: ,street Name: greet Unit #: 3 3 / 4 Department: Building i) e ument Type: (Plan) (Plot ermL TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof DaedIn3 Property Address: rQ Owner of Record: iii Assessors Map # 3 Lot # /" 7 Type of Occupancy: s c% Ala., New: k Renovation: Replacement: Plans Submitted: Yes No X Installing Company Name: � er - - A C00)-,,n3 ->_ t-} ect, t., n Company Street Address: i N nt,i)t City: nb;,tM Zip: 01 Wor Company Phone Number: - �, �, - .7 - � Estimated Cost: $ 21< Indicate total number of units in the applicable box below Family IN/1 1 &2 Basement 1St Floor o `_ N o L.T. M Roof 2 o 0 Air Handling Units X Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners X Ventilation Fans Energy Recovery Ventilators Fumaces- Oil Generators Other: Basic Building Code Commercial Basement 1St Floor $ u_ N 3rd Floor Roof" Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By-Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the ssachuseu ate Building Code, the International Mechanical Code, and all Taws /bylaws /regulations of the Town of ngton: ture: ICA e " t44k. S 9 tJ i p11 a/k /f /:3 7 Print Name: Type of License: License #: This Section for Office' Use, Only Perm Issued Date Received: 9� 22,31() Received by: Revised 12/31/09 proved Date: 0ANO Permit Number: /0 / L� `r 7" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 021]] It/ ss.gov/dia Workers' Compensation lnsuranee Affidavit: Butilders/Contractors/Eleetrieians/Plumbers ant nformation Address: Permit # Name (BusinessiOrganintionfindividual): Phone, 11: Please Print Le ibi / Are you an employer? Check the appropriate box: 1. 1 am a employer with 4. D 1 am a general contractor and 1 employees (full and/or part-time).* 2. El 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers' comp. insurance.t 5. [=:1 We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.) Type of project (required): 6. 0 New construction 7. 0 Remodeling 8. 0 Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.15a Other Mr/'U- k". *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. !Contractors 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. 1 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site ir*forma(jon, Insurance Company Narne: 6- Lc, B PsL IL NJ K 1\J CE Pclicy # or Self ins. Lie. ,5-1C)',30 (.2 7 Expiation Date: 1 Job Site Address: Act- _ City/State/Zip: 1---6 /74 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 ofbIG1., c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/o 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 Investications of the DiA. for instuance coverage:verification. I de hereb unc'er the pains and penalties of perjury that the in Signature: Phone: I - akin provided above is true an Date: 7 /2-6 /( Official use only. Do not ;yr& in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Permit/License # Contact Person: Phone ti: Information and instructions hiassachusetts General Laws chapter 352 requires all employers to provide -workers compensation for their employees. .PUrSA:ta to this statute, an eiriployee is defined as .every person inibe. EelP,riCe Of ti7JOInCT under any contract of hire. eyt-ii est ol implied, oral or written," An eniployer is defined as "an individual, par-tnership, association, corporation or other legal entity, or any twc or more cf Ore foregoing engaged in a flint enterprise, and including the legal representatives of a deceased employer, or the reex iVeT, or trustee of an individual, partnership, association or other legal entity, employing employees. Kowevei the cv,',ner of F dwelling house having not more than three apartments and who resides therein, or the occupant of the dweilirq.3 house of 03.;001er VV}10 employs person o dc., mairitenato-e, constroot;c4., ttrietiait on such dwelling hci3s.c . or or the giouruds o bui3o3iin,-. appurtenarn thereto shall no becat3sc t.;:f such ernoio,3Trier31 be de:med to be air emple-y,e:•:." 1401- ertaplet. fcz, §25(46) also states than "every state or kocal licensing agenq sta, withheld the iFSti5liCts' renewal of 2 license or permit to operate a_ business or to construct buildings hi the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, IvIGL chapter 152, §25C(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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(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 nasurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Depaituient 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 then self-insurance license number on the ap ropriate line, City or Town Officials Please be Sine 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 Inve,stigations has to contact you regarding the applicant, Please be sure 1.0 fill in the, permit/license 11111111-3er' which will lie3 used as a reference number. In addition,. an applicant that must submit multiple permititic,e,nse, 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 cop:), of the affidavit that has been officially stamped. or marked by the city 61! town may be provided to the applicant as proof that r valid affidavit is op file fer ,ftintre permits or- licenses, A new affidavit 11111St be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any busiuess or commercial venture (i,e. a deg license or permit to burn leaves etc,) said person is NOT required to cuniplete this affidavit. 'lire Office of Investigations would like lo thank you in advance for your Cooperation and should you have bave any questions, please do not liesita.te to give as a call, The Department's address, telephone and fax number: Revised 11-22-06 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations. 600 Washington Street Boston, MA 02111 TeL # 617-727-4900 ext 406 or 1-877 SSAFE Fax # 617-727-7749 ww-writass.goviclia Mai : Lot r,. c ;Department: O111itil;lg TOWN OF LEXINGTON Community Development Building Division :�O n = a - a ; n J` MO04 Ins ~° P 7. _ 'ri`t '_ ; ,gyp,,,, r The Commonwealth of Massachusetts State Board of Regulations and Standards Massachusetts State Building Code For one- and Two - Family Dwellings 7`h Edition APPLICATION FOR: ROOFING, SIDING, CONSTRUCTION SE VICES: WINDOWS, DOORS SITE INFORMATION: Not Applicable: License Number 76563 Expiration Date 12/18/2011 Permit # "7-173-7Date issued: / /b _ Work approved by: Property Address: 15 P(�r \ � P�Q1� Not Applicable X Registration Number Expiration Date Address: Historic District: Yes / No Assessors Map /Parcel # r%2 3, Provide name of Waste /Rubbish hauler All State Waste Address: 67 Perkins Ave. Brockton, MA 02302 Is this hauler currently permitted through the Health Department? Yes Phone # 1 -888 -559 -0909 Roofing 5900: (Note: Roofing is not permitted over more than one (1) existing layer. If two layers of roofing exist, then roof must be stripped before re- roofing.) Roofing shall be installed according to manufacturing recommendations. Proposed work: Number of squares Does this involve replacement of sheathing? Strip and re -roof Re -roof over existing single course Location on roof Yes/No Number of existing layers of roofing? Siding 5700: (Note: Electrical Permit required with application) Proposed work: Strip & re -side Re -side over existing Proposed material: Existing material: Electrical Permit: Yes/No Door Replacement: (Note: Maximum U .44) Number of replacement doors: 2. Estimated cost of work and material excluding electrical cost: PROPERTY OWNERSHIP /AUTHORIZED AGENT: Owner of Record: Name (printed) Lexington Housing Authority Mailing Address: 1 Countryside Village Lexington, MA 02420 Signature Phone # 781- 861 -0900 Authorized Agent: Name (prin1led): Signature: f1, Phone # 781- 861 -0900 Mailing Address: 1 Countryside Village Lexington, MA 02420 CONSTRUCTION SE VICES: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Not Applicable: License Number 76563 Expiration Date 12/18/2011 Address: 86 Bedford St. Lalseyille, MA 02347 Signature: CL.i („ Phone # 508- 583 -3999 Registered Home Improvement Contractor: Company Name: Not Applicable X Registration Number Expiration Date Address: Signature: Phone # Received by /date: ////7//O Fee: Receipt #: 9IQI' Issued By: die--4 Af-t- Map #: • 3 Lot #: Unit #: Street#: 2. 'treet ?Name :� 'Treet Unit #: Oepartment:3«31�i_ Document Type: (t E .n} (Piot (Per TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permi Property Address: 8,,q Odra/ y Owner of Record: Assessors Map # Lot # Type of Occupancy: New: Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: 5ukt- I/ Vxr Company Street Address: / P ) p Y /3 � v- �S�- /City: ,� l �;e,�'"i'C' �i� Zip Company Phone Number: (7'/J (/Z U 5 Estimated Cost: il to 3G 7- ") I NO Indicate total number of units in the applicable box below Basic Building Code Commercial M1 &2 Family Basement Joold Isl. 2nd Floor ■ 3rd Floor Roof Ground* Air Handling /Hydro Units '✓ Draft Inducers Oil fired Equip Evaporative & Refrigeration Coolers Kitchen Vent & Eaust Equipment Heat Pumps Pool Heater Range Hoods Vented to Exterior Process Piping Central Air Conditioners Roof Top Units Combustion Air Nentilation Fans Radiant Heat Energy Recovery Ventilators Hydro Air Systems Furnaces- Oil Central Air Conditioners Other: Other: Basic Building Code Commercial Basement $ u_ 2nd Floor 'a u. M Roof* 2 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Eaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and acc ate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the pe i issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Build' Code, t?e Int Tonal Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation Ins ran Affidavit eg 'red for all mechanical submissions Signature Print Name: u/y)6u5ier Time of License: This Section for Offical Use Only Permit fee: 30, CC3 Receipt # e56151/ License #: Date Received: (04% -0 Received by: roved Date: Permit or Alteratio ' umber: 10710 to -t5 Revised 8/4/10 AC d-1-6° met crud Map #: 4 Lot #: c Unit #: Street #: „titreet Name: E 66 450A/ /b =T eet Unit #: Oepartment: _ iEl;Iti_ i Dnenmment Tv.pe: I )L'. x1) tPlet) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862- 0500`x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: / V E nil o yt< rtP Owner of Record: t-},en r y TY/ e .v Assessors Map # VeZ Lot # g Type of Occupancy: (2e6 New: Renovation: Replacement: ✓' Plans Submitted: Yes No Installing Company Name: ' ' 1,4 e. 41 Company Street Address: Pc eetx Afir- Company Phone Number: C 1.1- 13 b City: tom Zip: o /To/ 37'2- Estimated Cost: $ ? 1?-4.0 Indicate total number of units in the applicable box below Air Handling tJnit Hydro Air Unit Evaporative Coolers Heat Pumps 1 &2 Family Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans c E 0 0 0 0 u- T o` 0 N 0 0 v • 0 0 Energy Recovery Ventilators fwraaees-Oil g z3,1 e../ D Generators Other: Basic Building Code Commercial Basement o u.. '- 0 u- CV' 3�d FicOor Roof Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. Aland survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: G+ -er or'- ° y) nsrper I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the Intemational Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: J,2„mc4 N4L g. __0, ©11 d..r -nGr aGi4i ? License #: Print Name: Type of License: Permit fee: /2 Issued By : This o' Section f or Off Recei Revised 12/31/09 c, a 1 U Only to Received:� / Received by: /1j*` pproved Date: .3-4.s../(0 Permit Number: ft 543/0 to ' $,6 /1(-,e-6J Map #: - Lot #: 1 7 0 Unit #: Street#: �-- 71-)Acb street Name: f�g /g a �4N XS Treet Unit #: Oepartment: 3��31ci n. Document Tvpe.: .. I17;" The Commonwealth of Massachusetts of Regulations and Standards Massachusetts Code For One and Two - Family Dwellings 7m Edition TOWN OF LEXINGTON Community Development a zs Building Department ` ri,,, ,. 1.$ ,�,~ State Board Ew . State Building APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH ONE/TWO FAMILY DWELLING SITE INFORMATION: Required: ( Actual: Property Address: 3v (\ s . -s 1-)yy v,1, Lot Area (sq.ft.) Assessors Map # S Parcel # / ? 0 Frontage(ft.) Historic District: Yes/ No 1 Historical or Architecturally significant buildings outside Historic District Yes/No { Zoning Special Permit: Yes/No BUILDING SETBACKS: Front Yard Side Yard Rear Yard Height Max. 40 ft. Required: 1 Actual: Required: I Actual: Required: ( Actual: Water Supply: Public: Private: FEMA Flood Zone: Zone: Sewage Disposal: Municipal: Private: Actual: Provide the name, of the Waste /Rubbish Address: l , r-,a t �-wa xr� A`)'- hauler: C '-Tb nc i Phone #: q7 7-- Q'1 L- 11'-11 Is this hauler currently Y L� rmitted through the Health Department? Yes/ti Total new construction or a 50% increase in floor area subject to Lexington Code § 120 (tree bylaw) Phone # / -e6a- (69.6 Yes/No //l 721 #,- iyiS if-13 "95'E Describe proposed work: D)v .-xi 571A/G- 1 ,41L 7 4-0-" 6 " 7 ,- y /.vs ve-,V 7a v 77 -,5 P /dr�.►.e . ). Estimated Cost excluding Land, Electrical, Plbg, Mech :, av -. NEW ONE/TWO FAMILY ONLY - LIST APPROPERIATE SQUARE FEET: Basement: (unfinished) (finished) 1st Floor: 2nd Floor: 3rd. Floor Garage: (attached) (unattached) Deck/porch (covered) (uncovered) Bedrooms #: Bathrooms #: PROPERTY OWNERSHIP /AUTHORIZED AGENT: MUST BE SIGNED BY OWNER OF RECORD Owner of Record: Name (printed) NI _A L v Mailing Address: -`i -1= w f- b �-k.-a 'f ©c.. Signature , (' iir Phone # '141- Wil,®i - LM Authorized Agent: Name (printed); h ,...uf I'a� r J� ',2 6 � ti'/ i Mailing Address: / Signature: ( 4'P Phone # / -e6a- (69.6 CONSTRUCTION SERVICES: Licensed Construction Supervisor: Name (Printed): \s_t1 Address: 7 k-\ c s'a. Phone # e03-0 Registered e Improvement Contractor: Company ame: j 81\ \Ono 3o r5, _i (" \c Address: cif -G Sinature :,4 /1414 t Phone # °(1 2-(3- oao7ro. This section for Official Use Only Signature: Not Applicable: License Number (3(.11--i L ( au/ Expiration Date orP Not Applicable: Registration Number (O( oto Expiration Date 1( oi Permit e: `�6S_ op Micro -film Fee: to Total Fee: y 7g Date Received: K, 496140 Received b : BUILDING COMMISSIONER: Receipt #: ,2.7 0 Permit #: fe9_47 "` f f 7 Approved Date. � qC ,,b The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Map # Lot # 600 Washington Street Address: Boston, MA 02111 Permit # www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): 0- D -) c' j T? t Address: LPL City /State /Zip: i `1 Phone #: j 1 to 3 -(P),, Are you an employer? Check the appropriate box: 4. 0 I am a general contractor and I have hired the sub - contractors listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.$ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] 1. EyI am a employer with 1 employees (full and/or part- time).* 2.0 I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 5.0 Type of project (required): 6. 0 New construction 7. 0 Remodeling 8. ® Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other *Any applicant that checks box #1 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 (Contractors 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: _., , L)r C — Policy # or Self -ins. Lic. #: p n CO o< f.-1 '1 0 \ 0 0 i Expiration Date: Job Site Address: ,3C1 G , City /State /Zip: Il6 Attach a copy of the workers' compensation policy declaration page (showing the policy number an . piration 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 certi1 dew, e ains and penalties o Signature: Phone #: ' ' ri m • .9 that the information provided above is true and correct. Date: fo 7--1 I a 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, 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 is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing 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 than 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, §25C(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, §25C(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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(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 Town 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 home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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 Tel. # 617- 727 -4900 ext 406 or 1 -$77- MASSAFE Fax # 617-727-7749 www.mass.gav /dia Revised 11 -22 -06 8/25/2009 8:03:16 AM 8938 @ 02/02 PRODUCER INSURED Acton Woodworks Inc 2 School Street Acton, MA 01720 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER TEE COVERAGE AFFORDED By THE POLICIES BELOW. COMPANIES AFFORDING COVERA(W - -4" 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 ciatTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIB DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO LTR TYPE OF MISIMANCE C.EKERAL LumuLny I I 1 1 1 I COMMERCIAL GENERAL UABILITT" I I MAIMS mum, Io�uft OWHERS& COMITULL1ORS PROT. POLICY MEMBER POLICY EFFECTIVE POLICY EV/RATION DATE (IIIMODITT) DATEMAMIDDITY) EMITS COMMENTS/ DESCRIPTION OF OPERATIONS OR OCATI : TOWN OF LEXIONGTON 1625 MASSACHUSETTS AVENUE LEXINGTON, MA 02420 • 411M-01.31, ABOVE DESCIMED POLICIES BE CANCELS= Boom THE EXP/RATION DATE , THE ISSUING CCOAPANY WILL/INDEAVOR TO MAIL Ig_WRITTENNOTICE TO IDE CEIGIFICA OLDER NAMED TO THE LEPT, BUTFA1LURETO MAIL SUCH NOTICE SHALL DAPOSE NO OBLIGATION unruly OP ANY KIND UPON, THE COMPANY, ITS AGENTS OR RIWRESENTATIVES. UFRORIZED REPRESENTATIVE 8523 THIS CARD MUST BE VISIBLE FROM THE STREET AT ALL TIMES AND ACCESSIBLE FOR INSPECTOR TO SIGN Failure to display or have card accessible will result in $50.00 Re- inspection fee Town of Lexington BUILDING PERMIT Job Weather Card Job Address:39icatr'bGottiS Permit No.io_A79_i, ! !r Issued: 6_?q_2oia Owner: (jh, i.e Contractor: 2e i' a Nature of Work: V r'ehv va,4 base hvt en t Conditions: ernergenC V eSC&-pe c.AI rescue naer.iher 11 ree ulteeJ in base yiew, mot ,l R Approval this permit shall not be construed as approval to set ide any w, rule, regulation, or ordinance or s1 /o condition(s) of any Board or Commission CONTRACTOR IS RESPONSIBLE FOR CONTACTING DIGSAFE PRIOR TO ANY EXCAVATION (1- 888 - DIGSAFE) Inspector must sign ALL APPLICABLE spaces Inspection Approved Not Approved EXCAVATION, SETBACKS, FOOTING FORMS & REINFORCING Place no concrete until above is signed FOUNDATION REINFORCING (if provided) FOUNDATION, WALL BRACING, DAMPPROOFING AND DRAINS (do not backfill until approved) Do not frame until above is signed and, if box is checked 0, as -built plot plan is filed with Building Dept. NOTE: Electr'cal, plumbing, mechanical and gas work require separate permits UNDERGROUND ELECTRICAL UNDERGROUND PLUMBING /GAS ROUGH ELECTRICAL ROUGH PLUMBING ROUGH GAS ROUGH MECHANICAL ROUGH FRAMING FIREPLACE THROAT INSULATION ABOVE CEILING (where applicable, for other than 1 or 2 family) Cover No Work Until All Applicable Inspections Above Are Signed As Approved FINAL ELECTRICAL FINAL PLUMBING FINAL GAS FINAL MECHANICAL FIRE DEPARTMENT APPROVAL FINAL BUILDING NOTICE TO HOMEOWNERS: ACCESS TO THE HOME IMPROVEMENT CONTRACTOR GUARANTY FUND IS NOT AVAILABLE IF WORK IS PERFORMED BY UNREGISTERED CONTRACTORS. H.I.C. CERTIFICATE NUMBER / O(o o? 6 ro For inspections, call: 781 - 862 -0500 • Building: X -715 • Electrical: X -215 • Plumbing /Gas /Mech.: X -212 Call at least 48 hours before required inspection Rev. 12/30/08 Building Commissioner /Leaa �,ctt= �rrEed. fo Map #: 5 Lot #: Unit #: Street#: .street Name: •rreet Unit #: Department: €__ din i)cc ment Type: (Pit.n) (Piot (Perm ). r TOWN OF LEXINGTON "sC.)1 APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 - 862 -0500 x -211 Fax: 781 - 861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 tv fec. P efA\ 78"1- 86a- c5to x 7fS erck 652%;(_ Is this application in conjunction with a building permit? YES # Property Address: /0 4)q/ii/Owner of Record: Assessors Map # 63 Lot # cn Type of Occupancy: New: Renovation: Replacement: V Plans Submitted: Yes No psi/4-e tRES. Installing Company Name: 4be . At. Company Street Address: 32 %tff7/ la. City: j/ 1''7 Zip: Ca 4,0 Company Phone Number: 77/ cgq w %/o Estimated Cost: $ /6 24 Indicate total number of units in the applicable box below Basic Building Code Commercial 0 E y I6 CO `o 0 LI 0 0 u- N 0 0 LL M 0 0 c c 2 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & E,diaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By Law: ` "" i'"( R‘PPA 2 EZ'7 O )X/ 7if 1 a 164, 0S& I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building de, the Intern . '. .1 Me anical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation Insur, c; Affida t rep for mechanical submissions Si• ature: ermit fee: Issued By : r�2A E�Pas77o /fr,4 Co • 84` Print Name: P?jZceS Tvpe of License: License #: This Section for Offical Use Only Date Received: 51�5�� Receipt # 7' 1 Revised 8/4/10 AC pproved Date: Received by: Permit or Alteration Number: to- 9301- 1 &2 Family Basement 1st Floor o N 3`d Floor Roof Ground* Air Handling /Hydro Units Evaporative & Refrigeration Coolers Heat Pumps Range Hoods Vented to Exterior Central Air Conditioners 9, Combustion Air Nentilation Fans Energy Recovery Ventilators Furnaces- Oil Other: -.1-' f~ Basic Building Code Commercial 0 E y I6 CO `o 0 LI 0 0 u- N 0 0 LL M 0 0 c c 2 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & E,diaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By Law: ` "" i'"( R‘PPA 2 EZ'7 O )X/ 7if 1 a 164, 0S& I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building de, the Intern . '. .1 Me anical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation Insur, c; Affida t rep for mechanical submissions Si• ature: ermit fee: Issued By : r�2A E�Pas77o /fr,4 Co • 84` Print Name: P?jZceS Tvpe of License: License #: This Section for Offical Use Only Date Received: 51�5�� Receipt # 7' 1 Revised 8/4/10 AC pproved Date: Received by: Permit or Alteration Number: to- 9301- - i-ego /itt,t 7)1,66d_ Map #: Lot #: Unit #: Street#: street Name: >rreet Unit #: rnitt #: /65' /// 2 Oepartrnent: Build. !ng iThettment TVpe: 1pE�ar� (Ftt!t� 4 TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PE T 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781-862-0500 x-211 Fax: 781-861-2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: c Qoa,ci Owner of Record: Assessors Map # /1 Lot # 7 (2\. Type of Occupancy: Eel, thou_ New: Renovation: Replacement: Plans Submitted: Yes No X Installing Company Name: Ccvvi-co-1 + 7--rtc - Company Street Address: 9 A jd ryhyte gt City: uJoix,t(r, Company Phone Number: -7,11-9- Zip: 6/10I Estimated Cost: $ y Indicate total number of units in the applicable box below MC5 1 & 2 Family Basement 0 u.. to 0 la: t, Li 0 Roof 4-6 c = Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement o LT y, 0 T- 3rd Floor Roof* Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be .required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. Al! equipment is subject to Lexington's Noise By-Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations p orm under the permit issued for this application will be in compliance with all pertinent provisions of the Ma chuse e Buildirg Code, the International Mechanical Code, and all laws/bylaws/regulations of the Town of I On: Signatur —41 x Prrcctiu Permit fe • Rec • t Print Name: Issued By : Revised 12/31/09 Type of License: This Section for Offical Us Only 6 Date Received: AA/200 C-1 377,11 License #: Received by: Approved Date: Permit Number: /0 ,04/X2eio 4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston, M4 02111 lt}I- 'li'.rrlless. t of /!fill Workers' Compensations Insura Applicant Infor°matioii Name 0 3usiness /Orgaruzationfindividual): Address :_._.._._, i" ki C ill /SIaleiZil . > Map It Address: Perfnil. # ce Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Legibly Are you an employer? Check the appropriate box: 4. 0 I am a general contractor and I have hired the sub - contractors listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.$ 5. 0 We area corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] *My applicant that checks box #I 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 the hire outside contractors must submit a new affidavit indicating such (Contractors that check this box must attached an additional sheet showing the naive of the sub - contractors and state whether or not those entities have employees. lithe sub - contractors have employees, they must provide their workers' comp. policy number. 1. ® I am a employer with employees (full and/or part-time).* 2.0 I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t . < (; Type of project (required): 6, 0 New construction 7. J Remodeling 8. 0 Demolition 9. [] Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other rorhai & Pad/ a . . 1“14. ram an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: G Is 13 P L. _LW S (-1 ANC(. N ET (AAA' fC .E=NC. Policy # or Self -ins. Lie L} U6 ej (3 6 Expiration Date: 1 d p 1 2 ,l ,72-0 Job Site Address: 9 Fie 1 City/State/Zip: / 4 .__ice 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 ofMGL 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 covera e verification. .1 do her ; i p under the pains and penalties ofperjury that the information provided above is true and correct. Signature: P one -Fay Date: 9 /,l. z / id 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Fu s . Pt t.0 this £tatitite, an Fit €p1bree is defined ss "...eV'ery person in the service of another under any contract of hire, E.`<:'prere Oi J33"r_plhec:, wrl o? An employer is defined as "an. individual, partnership, association, Corporation or other legal entity, or any two or more of the foregoing 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 than three apartri,ents and who resides therein, or the occupant of the dwelling house, Qf another 1ilG employs persons to do maintenance, construction Or J'el3air \VL'J "h. on such dwelling t1o3iS:C- OI OT; the grounds Oi'building appurtenant 1 }JPret(. shall 330i because- el such employment be deemed t0 be an e]ilpiQVe.r. +. MGL chapter 152, §25C(6) also states that "ever y state of 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, §25C(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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(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 'ropriate line. City or Town 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 pert-nit/license number" ;which will be used as a reference, manner, In addition, an applicant that must submit rr,ultiple permitilicense applications in any given year, need only submit one affidavit indicating curre,xt 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 home ov'ner or citizen is obtaining a License or permit not related to any business or commercial venture (i.e. r; dog license of permit to bun": 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 as 2 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 Revised 11 -22 -06 Tel. # 617.727- 4900 ext 4.06 or 1-877-MASSAFE Fax ## 617•727 -7749 wade.n a,ss,gov /dia COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE - BOARD OF LICEN PLUMBERS jAND RNG�AySFIITNEPLUMBER SUES THE ABOVE LIN�1$� IN MICHAEL C BERNASCONI 58 ALBATROSS RD QUINCY MA 02169 -2658 1 1 LICENSE NO. EXPIRATION DATE COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE - BOARD OF IN PLUMBERS AND GASFITTERS LICE LicEqgg SAmigaR(LUMBER MICHAEL C BERNASCONI 58 ALBATROSS RD MA 02169 -2658 QUINCY 1 LICENSE NO. EXPIRATION DATE SERIAL NO. COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE - BOARD OF BOARD OF SHEET METAL WORKERS AS A MASTER - UNRESTRICTED ISSUES THE ABOVE LICENSE TO: MICHAEL C BERNASCONI 58 ALBATROSS RD QUINCY MA 02169 -2658 • 73. LICENSE NO. EXPIRATION DATE SERIAL NO. ,_7,4A 7/t6t- Map #: d Lot #: / Unit #: Street#: (.3 • C� 'treet Name: ✓ / FE2 444/E Treet Unit #: milt #: /L2 />777'', Oepartrnent:«�it% i)ccItment T e_.: y�i d1:E02� (��Ot, TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 - 862 -0500 x -211 Fax: 781 - 861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # Property Address: 30 6dCVL (---v Owner of Record: paw l� z �,� /-v Assessors Map # U 1 Lot # 6 Type of Occupancy: A S New: Renovation: Replacement: L Plans Submitted: Yes No Installing Company Name: r2) p( A/C— Company Street Address: %V f ect s-r,L,/ S7 City: Z,,A 4/&'j /C"-/ Zip: 711 Company Phone Number: .2—PVC Estimated Cost: $ .NCO Indicate total number of units in the applicable box below 1 &2 Family 1 Basement ] 1st Floor C 2 "d Floor L 0 M Roof Ground" Air Handling /Hydro Units Evaporative & Refrigeration Coolers Heat Pumps Range Hoods Vented to Exterior Central Air Conditioners Combustion Air Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Other: Basic Building Code Commercial E' a) E a� c m 0 0 u- r 0 0 N 0 0 u- M 0 0 V 0 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Eaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the 3- it i ued for this application will be in compliance with all pertinent provisions of the Massachusetts State Buildin e, t. Intern. onal Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation ed for all mechahical sub ions Print Name: , (' Tvpe of License: License #: This Section for Offical Use Only Permit fee: /0V, Issued By : Receipt #• Date Received: /O/ /.5, Received by: pproved Date Permit or Alteration Number: �� J� Revised 8/4/10 AC maw MIR Jimmy The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): !i ¢ %V Address: / y 4Str City /State /Zip: Ze i 7&,m a W) / Phone #: � S —56 /d Are you an employer? Check the appropriate box: 1. EJ I am a employer with 4. 0 I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.$ 5. 0 We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t Type of project (required): 6. ®New construction 7. Etkemodeling 8. 0 Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other *Any applicant that checks box #1 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. Contractors 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: Z .2 (4 i �-fi /l! S , Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City /State /Zip: 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 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 ins e coverage verification. I do hereby certi Signature: Phone #: allies of perjury that the information provided above is true and correct. Date: GAL -g6 /o 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, 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 is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing 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 than 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, §25C(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, §25C(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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(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 Town Officials Please be sure that the affidavit is complete and printed legibly. The Depai tment 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 home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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 Revised 4 -24 -07 Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617-727-7749 www.mass.govidia JixA "1- d_teza 7)u,e Map #: t' 4 Lot #: Unit #: Street#: street Name: /4"--7/1/1. 44,(/ .Treet Unit #: 3?rmlt #: ,/l% — �0 Department: _3_t;i�i_ , 1)N-in-Dent Type: (PhD (F ) Term) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # r-NO� Property Address: oo Pr ka,,,.L Owner of Record: Z,,,,,�A.,,.s * Assessors Map # e zi Lot # / 3 Type of Occupancy: esccgtca, New: Renovation: Replacement: Plans Submitted: Yes Installing Company Name: Z, ,Q. IZ 57;;, Company Street Address: atp Atr7t. 57 City: ,(ihp • I�' qa4Os.r<i Zip: p Company Phone Number: 7 8 6-6y f ,gyp �3 Estimated Cost: $ 4-0-0641‘ Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement l L 0 t T 2nd Floor L 0 9 co o Ct Ground* Air Handling /Hydro Units Y Draft Inducers Oil fired Equip Evaporative & Refrigeration Coolers Kitchen Vent & Edaust Equipment Heat Pumps )4 Pool Heater Range Hoods Vented to Exterior Process Piping Central Air Conditioners Roof Top Units Combustion Air /Ventilation Fans Radiant Heat Energy Recovery Ventilators Hydro Air Systems Furnaces- Oil Central Air Conditioners Other: Other: Basic Building Code Commercial Basement I o r 2nd Floor I g u- M o Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Edaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Workers' Compensation Insur a 't required for all mechanical submissions AFTA0i, -Fte,ftrer.?•‘- slt nature: License #: p Print Name: Type of License: Permit fee: 1c7 Issued By : This Section for Offical Use Only Receipt ; Revised 8/4/10 AC Date Received: *500 Received by. proved Date: Pe rmit or Alteration umber: /02/2/6 /6 /e9 /.s The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business / Organization /Individual): „,„4 �[ t& .oj /Iy .4 " r - c- ) Address: a .!(14-ris� City /State /Zip: /V0 /ice[ ev dA(% D /�'l Phone #: 9' 7 6 Are you an employer? er? Check the a ro fiate box: Y P Y PP P I am a general contractor and I have hired the sub - contractors listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.t 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] 1 I am a employer with 4. ❑ employees (full and/or part- time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 6Wor 621 td Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13.1g Other rte,- *Any applicant that checks box #1 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. Contractors 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: Policy # or Self -ins. Lic. #: a/4 f '&52 0 rd Z' Expiration Date: /1)44/ t Job Site Address: t 5 f t Ft*, 4. o, City /State /Zip: L it-A/ 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 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 u e pains and amities of perjury that the information provided above is true and correct q7g ow 3 Signature: Phone #: iW% Date: 2-9 ` % O 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, 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 is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing 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 than 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, §25C(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, §25C(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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(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 Town 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 home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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 Revised 4 -24 -07 Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617- 727 -7749 www.mass.gov /dia 7211-e-d-- jyti die,4 Map #: 4? 3 Lot #: Unit #: Street #: 'treet Name: og,645 :;greet Unit #: _ `''rilli t #: Department: Building I):1cunie t Type: _5 ita t l �)f!t) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: ES 7<c) AT> Owner of Record: g1 L . Ys AA Assessors Map # 3 Lot # Type of Occupancy: New: Renovation: Replacement: ✓ Plans Submitted: Yes No Installing Company Name: C * i E r2 Company Street Address: &1J t-wM 5-7- City: dAnz751.1 , Zip: 02-0 Company Phone Number: (7S, Estimated Cost: $ ;2 5 6,00() Indicate total number of units in the applicable box below 1/W1&2 Family Basement s u_ ° u- N 0 u.. M Roof Ground* Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units I' Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: 6:6561.4 /06 -row I]Z. Basic Building Code Commercial Basement 1st Floor oo ti N 8 oo M Roof'* c o 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All @quipment is subject to Lexington's Noise By -Law: LUE F& t.iu E ,PERL- Arc_eivtE 1TT (ttac it r is P�.ACL 6N CCEL -1/Je rteu3 ER 7,svD awe- Ctf ILLL I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all Laws /bylaws /regulations of the Town of Lexingt, r� 4 Sigtr�ture: C'SE 114 5'-t- JANE -KAn4 Print Name: tlEFt AMFAmi i?k MAST rz. ?t ?E fr i t2. t ;L2''176 Type of License: License #: This Section for Offical Ube Qnly Permit fee: IS 3; 67 Z Issued By : Revised 12/31/09 Receipt #: ob ifc3 h/0 Date Received: 3 pproved Date: Received by: i' Permit Number: 10- 34 Ji(xA d-te-4 NYAL-d../ Map #: 5 6 Lot #: � ' L Unit #: Street#: 'trees Name: eKLiii/ �..� ;Trees Urnt #: '"rrnit #: Department: BLIntiin iInenrnent Tvne: { 210 1 i 1 i Perm `'_-/ r '1 TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: s-� �,,,{�p Owner of Record: Assessors Map # o Lot # / 3/ /3 Type of Occupancy: New: Renovation: Replacement: ,/ Plans Submitted: Yes No Installing Company Name: \ Company Street Address: 'it \‘‘‘\\ City: 6 Zip Company Phone Number: KA Estimated Cost: $ �a s �P y5 040 l Indicate total number of units in the applicable box below m E m' 0 0 LL. NT 0 0 cc.," 0 0 LL co o- 0 c 2 Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hood Exterior Vented to Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- 0il Generators Other. Basic Building Code Commercial Basement o u. T.- 2 "d Floor °o u. -8 Roof Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws/regulations of the Town of Lexington: Signature: Type of 'cense: License #: Permit fee: 30,.c0 Issued By : This Section for Offical 771y Receipt #: 97763 Date Received: g Received by: ttZ Approved Date //6 //0 Permit Number Revised 12/31/09 Map #: • Lot #: __Z 3 Unit #: Street #: street Name: /4- N'Al2-7!V' ;Jreet Unit #: ' rrnit #: Oepartrnent: 3 «,Idmg ! oe nenr Perm TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE $12 per one thousand valuation or any portion thereof Property Address: /12 Owner of Record: C-- a LA, 'r Assessors Map # Lot # / 3 / Type of Occupancy: I) New Renovation: Replacement: Plans Submitted: Yes No Installing Company Name G he / S " (-7`fie p Company Street Address 7 7 S,r c.7 City: (lit /.h (i2CZip :a 1 �' Company Phone Number: l' . 7S1 2 fi 6. 3 Estimated Cost: $ - Indicate total number of units in the applicable box below 0 E a) t6 m 0 0 LL , 0 0 (■ 0 0 M 00 cr v' 2 Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Basement $ u_ c- o o c- a N Commercial u- M Roof c 3 o 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: 0, 4- S ,?c�/✓ /� ,D ij e cn d o Hest/72i 0. 3 / 0A- /6 Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -La 1/ a I certify that t have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: 'L. / ' L - ' Cre,"J t' ^s /,3 I ``s-ce -1 Print Name: Type of License: License #: Signature: This Section for Offical Use 0 Permit fee: Issued By Revised 12 /31/09 Receipt #; Date Received: Approved Date: Received by: AOPermit Number: fe l�D Map #: Lot #: Unit#: Street #: Street Name: Street t_; n't rt: Permi6#: (30% Department.: Buat4ing Document Type: :.t. (Pi t TOWN OF LEXINGTON Community Development Building Division b < ` �.,p,� �F-ri us MOq4', U75 ,0t Q _ > z- A a� The Commonwealth of Massachusetts State Board of Regulations and Standards Massachusetts State Building Code For One- and Two - Family Dwellings 7`h Edition APPLICATION FOR: ROOFING, SIDING, WINDOWS, DOORS SITE INFORMATION: Not Applicable: License Number 76563 Permit # /0:13-7-PO ate issued: // / 4 Work approved by: Property Address: 0 _0 ' I • �� 0 • . yikeyille, Signature: Phone # 508 -583 -3999 Historic District: Yes / No Assessors Map /Parcel # 36 Registered Home Improvement Contractor: Company Name: Expiration Date Provide name of Waste /Rubbish hauler All State Waste Address: 67 Perkins Ave. Brockton, MA 02302 Is this hauler currently permitted through the Health Department? Yes Phone # 1- 888 - 559 -0909 Roofing 5900: (Note: Roofmg is not permitted over more than one (1) existing layer. If two layers of roofing exist, then roof must be stripped before re- roofing.) Roofmg shall be installed according to manufacturing recommendations. Proposed work: Strip and re -roof Re -roof over existing single course Number of squares Location on roof Does this involve replacement of sheathing? Yes/No Number of existing layers of roofing? Siding 5700: (Note: Electrical Permit required with application) Proposed work: Strip & re -side Re -side over existing Existing material: Proposed material: Electrical Permit: Yes/No Door Replacement: (Note: Maximum U .44) Number of replacement doors: 1 Estimated cost of work and material excluding electrical cost: 7 7O PROPERTY OWNERSHIP /AUTHORIZED AGENT: Owner of Record: Name (printed) Lexington Housing Authority Mailing Address: 1 Countryside Village Lexington, MA 02420 Signature Phone # 781 - 861 -0900 Authorized Agent: Name (print d):; Signature: Phone # 781 - 861 -0900 Mailing Address: 1 Countryside Village Lexington, MA 02420 CONSTRUCTION SER CES: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Not Applicable: License Number 76563 Expiration Date 12/18/2011 Address: 86 edfo d St. MA 02347 yikeyille, Signature: Phone # 508 -583 -3999 Not Applicable X Registration Number Registered Home Improvement Contractor: Company Name: Expiration Date Address: Signature: Phone # Received by /date: /1/1 7/10 Fee: '36 Receipt #: 02 9d/a Issued By: Jjuc_ di-0J /21,66,d__ Map #: 3 3 Lot #: Unit #: Street##: 'treet Name: / s,1i(."% ?Treet (Jnit #: '?rrni t #: 6' %7 Oepartment: o /O 57 7 ( :wr'ument Type: (t ��a { jot,) Perm)._ TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 -862 -0500 x -211 Fax: 781- 861 -2780 Type of Occupancy: F o Sa11 Indicate total number of units in the applicable box below • Basement 1st Floor 2"d Floor O u.. gm. o 0 � , C = 0 Air Handling Units 6 Baseboar• --; - -t Boile /Gas/Oil Centre • nditioners ' / Direct Vent Fireplace Draft Inducers Duct Coils Evaporative Coolers Fire Suppression , Generators Heat Pumps Heating Zones Hydro Air Systems Incinerators Kickspace Heaters Kitchen Equipment No Vent Heaters • Basement ■ o CC t- L O u'- N � O ti 0, I o g C 0 0 Pool Heater Process Piping Pumps Radiant Heat Radiators Range Hoods Refrigeration Units Roof Top Units Sprinkler Conn, , Sprinkler Heads Sprinkler Hose Conn. Steam Generators Steam Kettles Ventilation Fans Describe Project *Note: If any equipment is being placed outside of the footprint of thebuitding, indicate setbacks to property fine. A and survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: New Work ❑ Reolacement 0 Plans Submitted: ❑ 1 certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that ail mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the ICC Mechanical Code, and all laws/bylews/regulations of the Town of Lexington: Signature: Print Name: Type of License: License #: £OO /EGO 'd Z6L11 £L:90 0 LOZI O /90 960Z09tiL9L / 3NOZ 31M- 13:1uoJ3 For Office Use Only insurance O 'wet it Fee $ Receipt# Rafe Issued £OO /EGO 'd Z6L11 £L:90 0 LOZI O /90 960Z09tiL9L / 3NOZ 31M- 13:1uoJ3 Map #: Lot #: Unit #: Street #: titreet Name: Jreet Un)t #: '?Trott #: �-� ==� T / c Department: JF uiliimg t)antment Tvpe: (rt�.,2) iFlc?t errs TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 -862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: �01:c0 a S! Owner of Record: F,24, l 'Rec() Assessors Map # 96 Lot # Type of Occupancy: New: Renovation: Replacement: D< _Plans Submitted: Yes No Installing Company Name: rciA)& -ecr�� 9A .27 Company Street Address:9 / , d 5,L City: (2e,i4cc b /1//1- Zip:9 /7 Z., Company Phone Number: 9 349— 9g-z) Estimated Cost: $ 06 Indicate total number of units in the applicable box below 1/Ii&2 Family Basement j L. oo u_ ,,, `- L 0 u c, N L 0 u_ -2 M 0 o IX Ground* Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners X Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: rGl24,ifCe ^c,af-s x -l- C19 Basic Budding Code Commercial Basement o II ,— o° u- �(v o0 u_ co Roof* Ground* Generators bran Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed .. r the permit issued for this application will be in compliance with all pertinent provisions of the Massachus State % d fg Cope, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexin on: i.1�L`; 642fS 0 -w>54 al ,5', `YI . -the,5 Print Name: Type of License: Sign. re: License #: Permit fee: , D This Section for Offical Use Only Date Received: (II ell ID ed,,A0A...4._ Issued By : Approved Date: Receipt #: 2' Revised 12/31/09 Received by: L-1,/ n) Permit Number: ifd 1.,/,AA idle_ Map #: Lot #: Unit #: Street##: 'treet Name: Treet Unit #: 'ern2tt##: 6 Department: i).1eurnent Type: ( iLp) (P)oi) r TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 -862 -0500 x -211 Fax: 781- 861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # Property Address: ( t (d 1 e1 Rd, Owner of Record: V lo a/ 10\15 ky Assessors Map # 3 Lot # Type of Occupancy: re51 de c New: Renovation: Replacement: X Plans Submitted: Yes No X Installing Company Name: 0--CL.rnt5 \' C ru , i cc. Company Street Address: 17 We.,4 ) NO /City: NN e'._,i (° Zip: Gf Company Phone Number: L 17- 9(°- -f °' 'S', 51 Estimated Cost: $ Indicate total number of units in the applicable box below Family 1V" 1 & 2 Basement `o 0 o` 0 2 N o` o '2 M Roof v c ° 0 Air Handling /Hydro Units Evaporative & Refrigeration Coolers Heat Pumps Range Hoods Vented to Exterior Central Air Conditioners Combustion Air Nentilation Fans Energy Recovery Ventilators Furnaces- Oil; . Other: ' P. r rk. l 1._ ' wll r b+T 1 Basic Building Code Commercial Basement 1 1st Floor o N 3rd Floor Roof* Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is t tic /1 iefal,or) bC I subject to L xington's Noisy- By -Lfw,: l I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation Insur: ce Affid. it qui ed for all mechanical submissions r , 411r � ►� Vol 1 ' r ilLoci a ,4 01 I` Print Name: Tvpe of License: Permit fee: (©$,CY) Issued By : This Section for Offi al Use Only Receip 3 Date Received: t proved Date: Revised 8/4/10 AC License #: Received by: Permit or Alteration Number: to _ ILiby The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): A-144 eAtot.litej Fve-L Address: /72 (/AR--1(s 6 b 0 K �� Nc q City /State /Zip: Pau l-013 N ( i (-o Phone #: ;I7- 96 83 ?3 Are you an employer? Check the appropriate box: 1. 1.2. I am a employer with / 3 d 4. ❑ I am a general contractor and I have hired the sub - contractors listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.# 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] employees (full and/or part - time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t Type of project (required): 6. ❑ New construction 7. 0 Remodeling 8. [] Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13.4 Other 601 1( . ?y7fri- rff, r *Any applicant that checks box #1 must also fill out the section below showing their workers' compensati;,n policy information. t Homeowners who submit this affidavit indicating they are doing all ork and then hire outside contractors must submit a new affidavit indicating such. Contractors 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: Policy # or Self -ins. Lic. #: e !J i 0 ¢ 3 0O (7 00 Expiration Date: 6-'3 ( (( t Job Site Address: (f) s i� � , City /State /Zip: i i, it 1( {\ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). j�f1-0,,9 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. ,K1A- TiOiAL e/Z 5 4e I do hereby cefa *i/y urnderthe pa[nr a d e "aides of perjury that the information provided above is true and correct. Signature: Phone #: •C4 / Date: ib / /J 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 Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: 0 kW Board of Building Regulations and Standards Constration Supervisor License License: CS 302 RgSfricted,to,;., WILLIAM 86 MINK WILMING Department of Poiblic Safety One Ashburton Place, Rm 1301 Boston, Ma 02108 -1618 License: Oil Burner. Technician Certificate Number: BU 016785 Expires: 10 /25/2 WILLIAM F DOHERTY 86 MINK RUN RD WTT.MTNGTON. MA 01887 Expiration: 10/25/2011 Restricted To: 1517 elL - wea Department of P blic Safety One Ashburton Place, Rm 1301 Boston, M 02108 -1618 License: Refrigeration Contractor License Number: RC 001012 Expires: 10/25/24 WILLIAM F DOHERTY R6 MTNK RIJN RD Restricted To: 00 gge 04.,, atAwaritemea Department of P rf blic Safety One Ashburton Place, Rm 1301 Boston, Ma42108 -1618 License: Master Pipefitter License Number: PM 007405 Expires: 10/25/2011 WILLIAM F DOHERTY 86 MINK RUN RD WILMINGTON, MA 01887 'S -CA1 is 40M- 08 /08- DBSLIFORMCA108212008 Restricted To: 00 Tr. no: 1118.0 Keep top for receipt and change of address notification. Map #: Lat #: Unit #: Street #: Street Name: Street ,nttrt: Permi3#: ° Department: Budding Document 'y¢'c: (P1 CFlot) • TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781-862-0500 x -211 Fax: 781-861-2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # Property Address: 21 1 & -L Owner of Record: Assessors Map # Lot # �3 Type of Occupancy: New: Renovation: \'" Replacement: Plans Submitted: Yes No P Installing Company Name: C 4p) 01(\ I1'0 \ -- ���" J 4AD Company Street Address: 55`155 PV tAJ ST- City: I Zip: Company Phone Number: ?8l ��� tO` Estimated Cost: $ P, 000 o0 Indicate total number of units in the applicable box below MO\ M 1 &2 Family Basement 0 4 •— ° ' N 3rd Floor I o x c ° 0 Air Handling /Hydro Units X Evaporative & Refrigeration Coolers Heat Pumps Range Hoods Vented to Exterior Central Air Conditioners Combustion Air Nentilation Fans Energy Recovery Ventilators Furnaces- Oil Other: Other: Basic Building Code Commercial Basement .10old is °o N °o a M i o CC 6 0 U' Generators Draft Inducers Oil fired Equip Kitchen Vent & Eaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations erformed under - permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State uildin Cod-, t nternational Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation required for all n chanical sullmissio s Sic a • e: Print Name: t‘t€r MAL Type of License: License #: This Section for Offical Use Only Permit fee: c320.— �r Date Received: �P4) Issued By : /� Approv D te: Receipt #: 9 Revised 8/4/10 AC Received rm it or Alter �� /93 umber: The Commonwealth of Massachusetts Department of Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information Please Print Legibly OA t1M 1\14 O,Pkl Phone #: -t"[- t(& Name ( Business /Organization/Individual): Address: 5K (W3 City /State /Zip: 1?3DV' Are you an employer? Check the appropriate box: 1. I am a employer with (2_ 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] r Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.VI-Other AC/ *Any applicant that checks box #1 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. :Contractors 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. - tt ++ ,, Insurance Company Name: Gw I Eci -��e NS Policy # or Self -ins. Lic. #:A�� 4 4O Job Site Address: 2 kp1JCocL Sc Expiration Date: eQ' 22-' 1 1 City /State /Zip: ' 17YJ M4 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 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 agai , st the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of th ; DIA ft r nsurance coverage verification. I do hereby c Signature: Phone #: f' 'e th ins and penalties of perjury that the information provided above is true and correct. Date: lZ- - i0 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, 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 is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing 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 than 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, §25C(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, §25C(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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(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 Town 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 pewit /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 home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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 Revised 4 -24 -07 Tel. # 617- 727 -4900 ext 406 or 1- 877- MASSAFE Fax # 617 - 727 -7749 www.mass.gov /dia _LI(A tale_ d-tee-o Ag/t. \_/XL-d-/ Map #: Lot #: Unit #: Street#: street Name: rreet Unit #• 5 3 // 70e./C Oepartment: «31tii?n i) et'ment Type: St f�:,11 1.j (Perm' TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT' 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862.0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work aithorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 63 .,n cock 6¢ -Owner of Record: rno.10eAr %lir Assessors Map # 6 3 Lot # '?Y Type of Occupancy: Qesi►Dc vice_` New: Renovation: Replacement: V Plans Submitted: Yes No Installing Company Name: ,w,° A VI eA eiv v Company Street Address: Peo l? ox ) 55- City: We, ,b: or r` i N o... Zip: p 1$ o ) Company Phone Number: '7 1- 53 -3 Q l Estimated Cost: $ j 9 Si, d Indicate total number of units in the applicable box below Family 1V1[ 1 &2 Basement �' 2nd Floor I 3rd Floor "" 2 o Air Handling Units Hydro Air. Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators h- Fewaces- Oil Generators Other: Basic Building Code Commercial Basement 1 o. u 2nd Floor 3rd Floor C4 0 0 0 Generators Draft inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process .Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment s being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District wil require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws/regulations of the Town of Lexington: re: Permit fee: /O Issued By ..S ► Yvl ` N1 ft cat / 7t) T Bid )' , ` Print Name: Type of License: License #: This Section for Offical Use Only Receipt #: Date Received: Z- 2,4f -1 /' pproved Date: -a6 -I D Received by: Revised 12/31/09 Map #: Lot #: Umt #: Street is ; Jiti(A me__ /4,-6J 7iti&t Map #: Lot #: Unit #: Street #: itreet Name: Cf/ 4 __L. 4 0 _ ,A/( ?o JJreet Urnt #: 'ttrmit #:G? ¢department: B«3iji Document Type: 4 P'k212) ( _ of ) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as fora Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # (NO Property Address: Assessors Map #_ `� ►' ? coeL Owner of Record: Z; Lot # t 9 41,4 Type of Occupancy: CA 4c, New: Renovation: Replacement: / Plans Submitted: Yes No L/ Installing Company Name: C ;Jby C Z .1,.:C. Company Street Address: ck) ad\rii>LA City: 0-02 ; lL Zip: 1 y3 Company Phone Number: (it �7 - $ 74. _ 1 SA Estimated Cost: $ f h-e • 0 0 Indicate total number of units in the applicable box below Basic Building Code Commercial a) E o fY] 0 0 L 0 0 u- N 0 0 u- c) 0 0 c 0 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & E>dtaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject t Lexington's Noise By -Law: i`:lpl. _ 3' CA-3 '---(ovti-t--"C4- I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation Insurance Affidavit required for all mechanical submissions 1t� Print Name: Si attire: �2 La,Ln►{ Tvpe of License: License #: This Section for Offical Use Only Date Received: ,A dD Permit fee: Receipt Received by: Issued By : Approved Date: Permit or Alteration Number: Revised 8/4/10 AC 1 & 2 Family Basement °o 4 r _ °o C N 0 P_ M Roof Ground* Air Handling /Hydro Units Evaporative & Refrigeration Coolers Heat Pumps Range Hoods Vented to Exterior Central Air Conditioners L Combustion Air Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Other: c,,,t,; , 1„ i Basic Building Code Commercial a) E o fY] 0 0 L 0 0 u- N 0 0 u- c) 0 0 c 0 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & E>dtaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject t Lexington's Noise By -Law: i`:lpl. _ 3' CA-3 '---(ovti-t--"C4- I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation Insurance Affidavit required for all mechanical submissions 1t� Print Name: Si attire: �2 La,Ln►{ Tvpe of License: License #: This Section for Offical Use Only Date Received: ,A dD Permit fee: Receipt Received by: Issued By : Approved Date: Permit or Alteration Number: Revised 8/4/10 AC idle_ die-0 7it,e.t "ed.- Map #: Lot #: Unit #: Street#: ' treet Name greet Unit #: j?rrn�t #: !Department: d >ng , Doclurent Type: TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 35 Hartwell Avenue Owner of Record: Alexandria Real Estate Equities Assessors Map # Lot # Type of Occupancy: Commercial — R &D New: Renovation: X Replacement: Plans Submitted: Yes No Installing Company Name: Environmental Systems, Inc. Company Street Address: 6 Howard Ireland Drive City: Attleboro Zip: 02703 Company Phone Number: (508)226 -6006 Estimated Cost: $ 70,000.00 Indicate total number of units in the applicable box below Basic Building Code Commercial 1 & 2 Family Basement _ °o u- „, °o u- N _ °o u- 2 M Roof Ground* Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: Basic Building Code Commercial Basement 1St Floor V °o LL. N °o Li CO J Roof* Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: Modification of existing exhaust duct systems. Installation of one (1) new electric reheat. I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the achusetts State Bu}idi g ode, the International Mechanical Code, and all laws /bylaws /regulations of the Town of gton: James Baldasaro Refrigeration Contractor RC 105129 Print Name: Type of License: License #: Permit fee: 21/ This Section for Offical U ��� 2 Date Received: Receip . Revised 12/31/09 Received b Approved Date: %7 Permit Number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Environmental Systems, Inc. Address: 6 Howard Ireland Drive City /State /Zip: Attleboro, MA 02703 Phone #: (508)226 -6006 Are you an employer? Check the appropriate box: 4. ❑ I am a general contractor and I have hired the sub - contractors listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.: 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] 1. 0 I am a employer with 66 employees (full and/or part- time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12. ❑ Roof repairs 13. Other Mechanical *Any applicant that checks box #1 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. :Contractors 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 Employers Insurance Co Policy # or Self -ins. Lic. #: MCC20002180120 Job Site Address:35 Hartwell Avenue Expiration Date: 01/01/2011 City /State /Zip: Lexington, MA 02420 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 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 under the pains and pe lties of perjury that the information provided above is true and correct. 1 Signature: Phone #:(508)226 -6006 Date: 3/2311° 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Client #: 10383 ' ACORDTM CERTIFICATE OF LIABILITY INSURANCE 02/05/2010 TYPE OF INSURANCE PRODUCER Starkweather & Shepley PO Box 549 Providence, RI 02901 -0549 401 435 -3600 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Environmental Systems, Inc. 6 Howard Ireland Drive Attleboro, MA 02703 -0037 INSURER A: Peerless GENERAL LIABILITY INSURER B: Associated Employers Ins Co /AIM 12/31/09 INSURER C: Houston Casualty Co EACH OCCURRENCE INSURER D: Hanover X INSURER E: PREMISES (Ea occurrence) COVERAGES 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, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD'L INSRC TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM/DD/YY) POLICY EXPIRATION DATE (MM/DDIYY) LIMITS A GENERAL LIABILITY CBP8746208 12/31/09 12/31/10 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $300,000 CLAIMS MADE X OCCUR MED EXP (My one person) $10,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 —1 POLICY I 1I NEC R-1 LOC A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS BA8746008 12/31/09 12/31/10 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 X BODILY INJURY (Per person) $ X BODILY INJURY (Peracctdent) X PROPERTY DAMAGE (Per accident) GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESS /UMBRELLA LIABILITY CU8746408 12/31/09 12/31/10 EACH OCCURRENCE $5,000,000 OCCUR CLAIMS MADE AGGREGATE $5,000,000 $ DEDUCTIBLE RETENTION $ 10,000 $ X $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below MCC20002180120 01/01/10 01/01/11 X WCSTATU- 1 W. TORY LIMITS ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT OOO $1,000 ,000 C D OTHER Professional Liability Commercial Prop. H71016354 IHN6856009 01/01/10 01/01/10 01/01/11 01/01/11 $2,000,000 $5,000 Ded. Per Claim See Limits Below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION 10 Days for Non - Payment City of Lexington, MA 1625 Massachusetts Avenue Lexington, MA 02173 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPR^EySEE)NTATIVE tal eentAtetj ACORD 25 (2001/08) 1 of 2 #S251660/M248947 TLF © ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25S (2001/08) 2 of 2 #S2516601M248947 • [DEPARTMENT OF PUBLIC SAFETY Refrigeration Contractor License Number 6 \ 105129 f41 E e '� .1 .010 Tr. no: 854.0 X : �,. Rester MENTAL SYSTEMS.INC JAMES S . SALDA 50 BROOK ST . N A1TLEBORO, MA Commissioner l idale_ die-4 7itz Map #: -� Lot #: Unit #: Street #: •street Name: Treet Unjt #: ' °rmit #: / 6—oG' Department: Bitiitim . Doeuurnent Type: t taxi j d .1i1) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 - 2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof J % Property Address: //q7- / 9y Owner of Record: A`'© Ss y /c-v":-*1 Assessors Map # 3.5- Lot # (g9- Type of Occupancy: Cd e New: Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: s --e ir'%� L v //- s7 k sq Company Street Address: 6 % C w S 571 City: Zip: /'-'-'719 ® /9,.z/ Company Phone Number: ' / — 7 _ Estimated Cost: $ c3o c� Indicate total number of units in the applicable box below Air Handling Units, Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans c E 0 m 0 0 o 0 N 2 Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement o Nu_ 0 N 0 M Rbof g 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping 2 Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners, Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: X72® &Ot( 1 certify that 1 have the authority to make the foregoing application and that all of the information 1 have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all lla is/bylaws /regulati ns of the Town of Lexin • o e ft�ZfC� r' 7 ///3"4 y Type of License: Permit fee: '/ Print Name: License #: This Section for Offical Use O ly I Receipt #: q I Date Received: 6/3/10 I Received by: Approved Date: Permit Number: Revised 12 /31/09 Ate- /3/10 ter,:, ,t«a g-/t Map #: Lot #: Unit #: Street##: 0 street Name: ,¢ ar Lti,E LL ;rreet Unit #: Oepartment: din Document Type! "12 !pjot) Perm i4fr&- TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address:101 Hartwell Avenue Owner of Record: King 101 Hartwell LLC Assessors Map # ?( Lot # Type of Occupancy: titA; c►l Lei .r-ch New: Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: Environmental Systems, Inc. Company Street Address: 6 Howard Ireland Drive City: Attleboro, MA Zip: 02703 -4612 Company Phone Number: (508)226-6006 Estimated Cost: $ 33S 000,o 0 Indicate total number of units in the applicable box below 1 & 2 Family IN ii Basement _ °o w .- L oo Li N L °o M Roof k c 3 6 Air Handling Units Hydro Air Unit Evaporative Coolers 10 Heat Pumps Range Hoods Vented to Exterior Refrigeration Units 13 Central Air Conditioners 8 Ventilation Fans Energy Recovery Ventilators 1 Furnaces- Oil Generators Other: y Basic Building Code Commercial E N 0 2 $ i ) — °o 11 c N _ °o LL v M Roof* Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment 10 Pool Heater Process Piping Roof Top Units 13 Radiant Heat 8 Hydro Air Systems Central Air Conditioners 1 Other: y Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of ington: lames S.6.44ascro Print Name: �QtR °�.la+l 2�GTor' /05 / 2 q Type o License: License #: Permit fee: "11 Receipt Pi- 1/D Issued By : Revised 12/31/09 This Section for Offical Use Only 3 4 %q Received by: Date Received: Approved Dater 020/0 Permit Number: i /6 7 a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers nt For Applicant Information Name ( Business /organization/Individual): Address: 6 Howard Ireland Drive Please Print Legibly Environmental Systems, Inc. City /State /Zip: Attleboro, MA 02703 -4612 Phone #: (508)226 -6006 Are you an employer? Check the appropriate box: 1. 0 I am a employer with 70 4. ❑ I am a general contractor and I employees (full and/or part- time). * have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. Other HVAC Mechanical *Any applicant that checks box #1 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. :Contractors 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 Employers Insurance Company Policy # or Self -ins. Lic. #: MCC20002180120 Expiration Date: 01/01/2011 Job Site Address:101 Hartwell Avenue City /State /Zip :Lexington, MA 02421 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 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 under the p J Signature: Phone #:(508)226 -6006 s and penalties of perjury that the information provided above is true and correct. Date: 09/13/2010 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 Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Client #: 1038 ACORDTM CERTIFICATE OF LIABILITY INSURANCE 01/05/2010 1/05/2010 TYPE OF INSURANCE PRODUCER Starkweather & Shepley PO Box 549 Providence, RI 02901 -0549 401 435 -3600 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Environmental Systems, Inc. 6 Howard Ireland Drive Attleboro, MA 02703 -0037 INSURER A: Peerless GENERAL LIABILITY INSURER 5: Associated Employers Ins Co /A1M 12/31/09 INSURER C: Houston Casualty Co EACH OCCURRENCE INSURER D: X INSURER E: DAMAGES (RENTED PREMISES (Ea oxunencel COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR LTR ADD'L INSRC TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM /DD/YY) POLICY EXPIRATION DATE (MM/DD/YY) LIMITS A GENERAL LIABILITY 8746208 12/31/09 12/31/10 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGES (RENTED PREMISES (Ea oxunencel $300,000 $10,000 CLAIMS MADE X OCCUR MED EXP (Any one person) PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GENt AGGREGATE LIMIT APPLIES PER: —1 PRODUCTS - COMP /OP AGG $2,000,000 POLICY rid I 72-1: I^ I LOC A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS Drive Other Car 8746008 12/31/09 12/31/10 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 X BODILY INJURY (Per person) $ X BODILY INJURY (Per accident) $ X X PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ EA ACC OTHER THAN $ AUTO ONLY: AGG $ A EXCESS /UMBRELLA LIABILITY OCCUR [-1 CLAIMS MADE DEDUCTIBLE RETENTION $ 10000 8746408 12/31/09 12/31 /10 EACH OCCURRENCE $5,000,000 X l AGGREGATE $5 000 000 $ H $ X $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER /EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below MCC20002180120 01/01/10 01/01/11 X' WC STATU- l IOTH- TO$Y LIMITS ER E.L. EACH ACCIDENT $1,000,000 $1,000,000 E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $1,000,000 C OTHER Professional Liability H71016354 01/01/10 01/01/11 $2,000,000 $5,000 Ded. Per Claim DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS RE: HVAC /Control Work CERTIFICATE HOLDER CANCELLATION 10 Days for Non- Payment Town of Lexington 1625 Massachusetts Avenue Lexington, MA 02420 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL !In DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE - `I',61.6,401• 4+ .1, Cs.1I -U. t- ACORD 25 (2001/08) 1 of 2 #S246493/M246194 JMR © ACORD CORPORATION 1988 f • • d 9/71e owvnr.kzeaea( c ackateeXt DEPARTMENT OF PUBLIC.$AFETY Wri46Titiciri Contractor License NumbeC 105129 Ex 10 Tr. no: 854.0 NMENTAL. SYSTEMS,INC Res JAMES S . SAWA 50 BROOK ST N AITLEBORO, MA J.J(A Mt_ d-Ig4 //tIt Ae_eA_ Map #: 3 0 Lott 6 LS. Unit #: Street#: •treet Name: ,/"�5-77No s greet tJntt #• '"rn:it 4: Oepartment: Document Tvpe: !& n' (Pio ,ec/g TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781-862-0500 x -211 Fax: 781-861-2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # ry 6 NO Property Address: ,, s� = ry s Owner of Record: i�a�� �tGl~l Assessors Map # Co Lot # zit(' 3 Type of Occupancy: 2 e S; r 'LiQ No New: Renovation: Replacement: V Flans Submitted: Yes Installing Company Name: c),, A Co 757.0 5 -1,--1 c- Company Street Address: If Cot.,. -.As 64 City: Ir,s , Zip: („g,g Company Phone Number0 ")$ t g� 3$ q Estimated Cost: $ i091°° Indicate total number of units in the applicable box below Family 1N/1 1 &2 Basement o 0 u- N r" `o 0 LI N o o I M Roof a c 2 U Air Handling /Hydro Units Evaporative & Refrigeration Coolers Heat Pumps Range Hoods Vented to Exterior Central Air Conditioners Combustion Air Nentilation Faris Energy Recovery Ventilators Furnaces- Oil t Other: Other: Basic Building Code Commercial Basement. 0 it r- c) N 00 Li v M L Roof` c o 6 Generators Draft Inducers Oil fired Equip Kitchen Vent & E)biaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property. line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will re uire prior approval of the Historic Diricts Commission. All equipment is subject to Lexington's Noise By -Law: �e �CC�+er' I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations d for this application will be in compliance with all pertinent provisions of the Massachusetts State Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Workers' Compensation performed under the ding Code, the I avit or all m,ez nical submis ons Lc n, Print Name: mature: Type of License: License #: This Section for Offical Use Only Permit fee: oo e.eceipt #: Issued By : Revised 8/4/10 AC Date Received: /Ap //, j, , ved Date: / / Permit or Alteration Number: /a %a//ra io - /s/810 Received by: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Please Print Legibly Applicant Information Name ( Business /Organization/Individual): La mcv Sys.-f eArrtS,, 1 r > Address: `-f m t -nc1 s ex a-ris_ City /State/Zip: i ta s 6o\r-D, .4- Phone #: Are u an employer? Check the appropriate box: 1. ( I am a employer with t:Q C) • 4. ❑ I am a general contractor and I employees (full and/or part- time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub - contractors listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.: 5. 0 We are a corporation and its officers have exercised their right of exemption per MGL c. 152,. § 1(4), and we have no employees. [No workers' comp. insurance required.] -^* — 3 Z1z Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *My applicant that checks box #1 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. Contractors 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 ernployees, 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: t4 +1 Ct (\41 ra, Policy # or Self -ins. Lic. #: W /s .005 /3.6-0 '1 Expiration Date: 4// /2. 0/ Job Site Address: / get-s s ��� °�� City/State/Zip: LeXlny�rL./ �0���? -� 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 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 under the pains and penalties of perjury that the information provided above is true and correct Signature:- _ . .. Date: Phone #: l 1,S- 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: NCCI Co. No.: 29211 1. INSURED: Lamco Systems, Inc. 4 Cummings Road Tyngsboro, MA 01879 Atlantic Charter Insurance Company Policy Number: WCA00513503 Prior Policy Number: WCA00513502 Business Type: Corporation Federal ID Number:042437642 Risk ID Number: SIC:9999 Other Named Insured: Other Work Places: Producer: Appleby & Wyman Insurance Agency, Inc. PO Box 330 Westford, MA 01886 NONCLASSIFIABLE ESTABLISHMENTS . POLICY PERIOD: The Policy Period Is From: 4/1/2010 To 4/1/2011 12:01 A.M. Standard Time at The Insured Mailing Address 3. COVERAGES: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insured: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A All states except Monopolistic State Fund States D. This policy includes these endorsements and schedules: See WCE105 RECEIVED MAR 15 201g . COVERAGES: Classifications The premium for this policy will be determined by our Manual of Rules, Classifications, Rates & Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate Per Estimated Estimated Annual $100 of Annual No. Remuneration Remuneration Premium See WC 00 00 01 Minimum Premium: Deposit Premium: $500 $5,584 Interim Adjustment: Annually Servicing Office: 25 New Chardon Street Boston, MA 02114 -4721 Total Estimated Premium Surcharge(s) Total Premium an Surcharge(s) $24,126 1,965 $26,091 Issue Date 03/12/2010 Countersigned By: Copyright 1987 National Council on Compensation Insurance Date -- Ik-10 Form: 100m t. JJ(A d-16J Map #: Lot #: Unit #: Street#: itreet Name: , 7, ./ E� Treet Unit #: Department: _ ui14i�i - Document Type: {PL n) (PIO i''(Perax, _ TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: gdrn Owner of Record: \2\!'lu)' 1-c&Ne Ozn-s4, Assessors Map # - Lot # a.. Type of Occupancy: s c vr.2, New: (/ Renovation: Replacement: Plans Submitted: Yes V No Installing Company Name: . 1 r� \ C- Company Street Address: j di d City: c ivvt U Company Phone Number: PCP) Estimated Cost: $ C(() Indicate total number of units in the applicable box below` 1 &2 Family Basement LL 2"d Floor I I - Roof 1 ° Air Handling Units Hydro Air: Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners — iia -.-6e— U Ventilation Fans Energy Recovery Ventilators Fumaces- Oil Generators Other: Basic Building Code Commercial Basement I IJoold ts 2nd Floor o M Roof` Ground* Generators Draft Inducers Oilfired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Signature: Print Name: Type of License: License #: Permit fee: Issued By : Revised 12/31/09 Thisfiection for Offical Use Only Receipt #. 125 I Date Received: gott- 514t-o Received by: proved Date: /5 j0 Permit Number: to -3G jjk / 0 ).J 7A, e,t e Map #: a 4 Lot #: / Unit #: Street#: Street Name: //L( D 57A AD ,Tweet Unit #: ' °rmi t #: / - 7/ z }department: Building D:ucurnent Type: (Tian) (Plot) errn 1 TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as fora Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Mir um fee charged $30.00 Is this application in conjunction with a building permit? YES # l0 _769-g) NO PP conjunction g P Property Address: as u 01 ),SO >J -b Owner of Record: ,j Amt S (0 U LTTT Assessors Map # at-t Lot # 1 to Type of Occupancy: ', LS , New: Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: SCOTIA L R'N 26 To E. (4U L I M L Company Street Address: (p a S PARi< ST. City: t R 6 Zip: 8,136a Company Phone Number: f O. -- S Q 4 Oa Estimated Cost: $ 13, oc j Indicate total number of units in the applicable box below Basic Building Code Commercial 1 & 2 Family Basement 1 _ °o " N � _ °o " C N _ °o `- M Roof Ground* Air Handling /Hydro Units Draft Inducers Oil fired Equip Evaporative & Refrigeration Coolers Kitchen Vent & E *iaust Equipment Heat Pumps Pool Heater Range Hoods Vented to Exterior Process Piping Central Air Conditioners Roof Top Units Combustion Air Nentilation Fans ,3 Radiant Heat Energy Recovery Ventilators Hydro Air Systems Furnaces- Oil Central Air Conditioners Other: Other: Basic Building Code Commercial Basement $ u- <- °o I-1- N °o I-1- o M 45 c 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & E *iaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: AC Lo __ NSL,R,S SI=T 6y L- F-1 SI )L G1= Nom L ?A( R, /my L I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws/regulations of the Town of Lexington: Workers' Compensation sure ce A avit uired for all mechanical submissions 1M MT eft. < L11. 61 4 Signature: ILLR4. AmtL of 1A %1AL ohith _ Print Name: Type of License: License #: Permit fee: if-4T Issued By : Revised 8/4/10 AC This Section for Offical Use Only Receipt #: 02plr Date Received: /07 Approved Date / 0 Permit o .r- er:1 32_ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information yy�� /Pleases )Print Legibly Name ( Business /Organization/Individual): 5 ®U-T N l � 261u E �11. r1 C . . of ( Address: f ( 1))1AI a STI City /State /Zip: TA U k T f) PI l ft Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.t 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.]. ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] Ty e of project (required): 6. New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors 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. n C Insurance Company Name: 1L AU1-' `n ` S 1 .0g . Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: a 11 L)1 &3 V City /State /Zip: Lk) )6VLt-T/)ir.) rT 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 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 rtify, u der the ins a j enasties of ; rjury that the information provided above is true and correct Signature: ,i/`1 Phone #: 5O — �"1L'-%aa 0 Date: 1 V ' - 1 U 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, 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 is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing 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 than 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, §25C(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, §25C(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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(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 Town 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 home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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 Revised 4 -24 -07 Tel. # 617 -727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617 -727 -7749 www.mass.gov /dia &Itxy) "rzo d-eg4 mat A„, Map #: • Lot #: Unit #: Street#: •street Name: 1.reet Unit #: �armi t #: Department: Dslcatment Type: Building (PEn1) (Plot TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand 'valuation or any portion thereof Property Address: /II i, i o r� Owner of Record: Elm � ; n Ut 41 Assessors Map # Lot # Type of Occupancy: New: Renovation: K Replacement: Plans Submitted: Yes Installing Company Name: ( Pl 0 wt Co r - 11 C n Company Street Address: LtR W h 't('tJc Qa e((. City: C. (a u fl \ Company Phone Number: (- 3Q' 7 1 Estimated Cost: $ e Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement I LL , 0 LL N 0 LL 'en Roof 3 ° (D Air Handling Units Draft Inducers Oil fired Equip Hydro Air. Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners ✓' ✓ . Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: s- Oil — Boi ev- Generators Other: SA P&LS' kirl l!. an 4 ,*) r, Basic Building Code Commercial Basement o LL T... 2"`' Floor I 9- - c) °o 0 //nom� V Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat ✓' ✓ . Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: 1 certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all Taws /bylaws /regulations of the Town of f.,rxM�to L411 Print Name: Type of License: Permit fee: 96 Issued By : .08 Revised 12131/09 License #: This Section for Offical Use Only Receipt #:: az Date Received: Z' Z 5-4) Received by: Approved Date: .2.-?3- p Permit Number: oe- Map #: Lot #: Unit& Street #: Street Na. ftrratt Department: Document `Pipe:: of:AA id aY- d " 7/1"--e NYAL-4,/ A-d/ Map #: 3 9a Lot #: 4- `% 44-- Unit #: Street#: 7 street Name; �^ Treet Unit #• '"rant #: Oepartment: BuiIdinR Document Type: (Pian) (Plot TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30,00 Is this application in conjunction with a building permit? YES # Property Address:1\ 10,0 6c, )1 �mIck Owner of Record: Assessors Map # 302 Lot # (LP 6- Type of Occupancy: 1 -l' c f' -Q New: Renovation: Replacement: ,/ Plans Submitted: Yes No Installing Company Name: C,1i 1,A2,` n•Q. 1PR S Company Street Address: c 1C k_ City: tic- - Zip: 0 I NO t/ Company Phone Number: "j - c.Han —an b- 9 Estimated Cost: $ ► (13Q o Indicate total number of units in the applicable box below Basic Building Code Commercial 0) E 0 t0 m 0 115 0 N V 0 2 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws/regulations of the Town of Lexington: Workers' Compensation Insurance Affidavit required for all mechanical submissions 7173 Type of ice se: This Section for Offical Use Only !_ice/ 743 Permit fee: t y`r! 0 Date Received: Issued By : ' roved Date: it+ od,ir Revised 8/4/10 AC Receipt #• Div Received by: /}-c Permit or Alteration Number: /0- f,234/ 1 at 2 Family Basement O 7, 2nd Floor O u_ Roof C 2 Air Handling /Hydro Units Evaporative & Refrigeration Coolers Heat Pumps Range Hoods Vented to Exterior Central Air Conditioners Combustion Air Nentilation Fans Energy Recovery Ventilators Furnaces- Oil Other: Basic Building Code Commercial 0) E 0 t0 m 0 115 0 N V 0 2 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws/regulations of the Town of Lexington: Workers' Compensation Insurance Affidavit required for all mechanical submissions 7173 Type of ice se: This Section for Offical Use Only !_ice/ 743 Permit fee: t y`r! 0 Date Received: Issued By : ' roved Date: it+ od,ir Revised 8/4/10 AC Receipt #• Div Received by: /}-c Permit or Alteration Number: /0- f,234/ J,AA "-a° ,1.t 44— .A64./e4e_f_epe._ Map #: 3- Lot #: 3 3 Unit #: Street##: 8 •9treet Name: Z /96.o/7`7 •Treet Unit #: '".rmit #: /6 -- 11�5/. Oepartment: Dui Wi_!n i) 1!ment Tvpe: 4t t• mj i 'Ic�t rtn TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PE T 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: ?8l-862-0500x-2]1 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: l acrm,`Q, SfrPe - Owner of Record: 7d„ -ric,,- Assessors Map # 5/ Lot # Type of Occupancy: gerkiefr,ce New: X Renovation: Replacement: Plans Submitted: Yes No k Installing Company Name: 1e1+1- \ Cop + }leti - ,TnC. Company Street Address: 9 Jl, me,tole Sfletik City: w�i u(4, mfg. Zip: Company Phone Number: -7f /- 223 - ,C11cf Estimated Cost: $ Indicate total number of units in the applicable box below M 1 &2 Family C 0 E 0 m 0 0 LT— In' L 0 0 u- iv 0 0 CO o 0 c c 2 co Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial 0 E 0 0 m 0 0 0 Cv 0 0 t- o 0 2 C9 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be .required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: ii oYrp doc-11,5-- /tic /n -RI Crjto,i I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations . . med under the permit issued for this application will be in compliance with all pertinent provisions of the assachusetts uilding Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of ng Sig ature: Pe 't fee: Issued ‘44.1kR eM.a.sctl n1 i�1.txS P6` Print Name: eceipt # Date Received: Type of License: (573 License #: Revised 12/31/09 Received by: roved Date: ty/a„ I Jjl� Permit Number: j2 � �/ 4 The Commonwealth of Massachusetts Department of Industrial Accidents' Office of investigations 600 Washington Street Boslon, AL4 02111 www.mass,.gov/dia Workers Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers A cant Infortnatiow- Please Print.,Letibly Name (Businesstorganintionfindivid1a1) :_____c__e_L,-2,---(7,,, __ ± Map # Lot # Address: Permit # A City/StatelZipc ,„AJ - --- Are you an employer? Check the appropriate box: 1. E 1 airt a employer with employees (full and/or part-time).* 2. am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. fl 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. 1 am a general contractor and have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers' comp. insurance.4 We are a corporation and its officers have exercised their right of exemption per MU, c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] 1 5 0 Type of project (required): 6. El New construction 7. D Remodeling 8. D Demolition 9. D Building addition 10.0 Electrical repairs or additions 11.D Plumbing repairs or additions 12.0 Roof repairs 13.E1 Other ; / 4 d fyip_zr *Any applicant that checks box #1 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 Contractors 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. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site In ournation. Insurance Company Nairte: Lj3jL C../-:-11\) K) J:NC, Policy or Self-ins. Lie. 77: 5 ,c'ej-ci 6 ;,2ci Expiration Date: 1 it a / 'Lia, Yob Site Address: i i I,Ck Cott Icp_21- City/State/Zip: Lexilv_t_dirfkze_____ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dale). Failure to secure coverage as required under Section 25A ofIAGI c. 152, can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/o 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 forNvarded to the Office of v stioils of the DIA for insurance co ei e erification . i/o hereby cert,i under the pains and penalties ofperjury that the information provided above is true and correct Signature. Date: Phone #: • 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 (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Ivlassachusetis Gene;ral Law,s chapter 1.52 recoil-es all employers to provide workers' compensation for their employees. ForsuaM to this statute, an al4,10Yee is defined as ",..every person M the service of ancIiher under any contract of trite; ess k)r implied, oral m written." An employer is defincd zs "an individual, pat-tiler ship, 4SSOCiation, corporation 01 other legal entity, or ally two or more Of the foregoing engaged' in a on enterprise, and including the legal representatives of clece,ased ernilloyer, or the rt,•ceiver or trustee of an individual, partnership, essocialion o othet legal entity, employing ernplciyeea. However the owner of a dwelling house having not Inure than three apartmeri ts. and who resides therein; or the occupant of the deihi :crc nfarotic.r w)-,0 oinoloys r,ersona le, d Inaintenaiact colistructiou or k such dwelling honse or on ,..Tiotirida bui1dir4i appurtenant tr a11 not beesuaT ef anoli emp1oyme1d be doomed 't.o be at employer," IN/1(31_, chaplei 152, §25C(6) also states that "e. 'very s-:ate o iocai eetiaiog agency stifM tiUt ieskatick.o; renewal of ra license or permit to operate a business or to cousiruct buildings hi the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its politicarrsubdivisions 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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(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 fepartment of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the afidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the,Deiiartment of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtaiii-a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter then self-insurance license number on tho apropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of tire affidavit for you to fill cut in the event the Office of Investigations has to contact you regarding e applicant, Please be surc to, fill in the porTnit/license numb::: which be used as a reference, numbc: t. In addition an applicart that inuEl submit multi* pffroimicTrise applic,ations in any given year, :need only submit one affidavit indicating cuirent 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 cr marked by the city or town may be. provided to the applicant as proof that a valid affidavit is on iii for future permits or licenses. i new affidavit most h filled out each year Where, a home owner_ or citizen is obtaining a license or permit not related to any business or commercial venture (i.e, a dog licensa, or perrnit le bun. 'leaves etc,) said posson iF NOT required to complete this affidavit. The Office of-Investigations would like to thank you n advance for 'our cooperation and should you have any question, please do not hesitate to give its a call, The Department's address, telephone and fax number: Revised 11-22-06 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www,tbass.govklia A,„/ Map #: Lot #: Unit #: Street #: / ___ 'treet Name: Z- o v77/�� ;rreet Unit #: ' ,trmit #: Department: Buihl g Dorn rent Type: (plot ENTERED r TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 3 - 213 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 1 Y\i a. Owner of Record: C Are Moociq Assessors Map # ---1/. Lot # Type of Occupancy: RP New: Renovation: Replacement: f Plans Submitted: Yes No Installing Company Name: ''j4J;- -: ltanh;i y 4-7/ea/if( : / ne--. Company Street Address: j !o, atk /4425— City: rl i Irl��2) ✓i Zip: 0461* Company Phone Number: 61)7S yV( 3 -707 09 --/7a /3 Estimated Cost: $ 11 (gyp Indicate total number of units in the applicable box below A /1 1 &2 Family Basement _ °o " 2nd Floor °o D co Roof j Ground* Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: a- tce-- 2pi.4e. / Basic Building Code Commercial Basement o L+- o° U. N °o t- CO �- o -6 E 0 Generators Draft Inducers Oilfired Equip. Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexingt• n: Signature: Print Name: Reif pc(I.- Type of License: let)/ License #: This Section for Offical Use On y Receipt #: r/5 Date Received: a/ /®v Received by: Approved D te: Permit urnbe Revised 12/31/09 Map #: Lot #: Unit #: Srree •■•■■■ ■V•6.M.•■■•■•■■■• MNICINII■■ ,r4./ v&ourewm. Zoi DOCIIIIie'11- Type: jiliD flOt / Q'.r t fizeecz Map #: / Lott Unit #: Street#: itreet Name: Treet Unit #: ?department: Bill it� Document Type: (Plan) (Pk (Perm' TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof i �� Property Address: -r� -�-�ti . Owner of Record: J _ Assessors Map ="' Lot # f' D Type of Occupancy: New: Renovation: Replacement: Plans Submitted: Yes Installing Company Name: Company Street Address: Construction Specialtle ity: P, O. Box 53 Company Phone Number: Stoneham. MA 02160 6 --`1/ c� Indicate total number o unrfs in the applicable box below Zip: Estimated Cost: $ Basic Building Code Commercial 1.2 Family Basement __ °o N u_ `- °o LL C N 1 JooId pie Roof c L o Air Handling Units Hydro Air Unit Draft Inducers Oil fired Equip Evaporative Coolers Kitchen Vent & Exhaust Equipment Heat Pumps Pool Heater Range Hoods Vented to Exterior Process Piping Refrigeration Units Roof Top Units Central Air Conditioners Radiant Heat Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Central Air Conditioners Generators Other: Other: OF a7Lp" Basic Building Code Commercial Basement o i H ti u- 2 °o t D Roof* Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: OF a7Lp" Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Signature: I (,1 Fri Ai Ai Print Name: Type of License: License #: Permit fee: Issued By : This Section for Offical Use Onl Revised 12/31/09 roved Date: // /a /a Received by Permit Numb LC-7] cf ot itz: • ,„ • , C.,09•11•41.4.1iIngfon S'irr4.1 11 cln:e fa-Co ' err I • , nipsfivi on• rivIce .,(,!7;471'11 ConstructidriP • 766241#/i(r 1"mix , es P.O. Box 53 Plionc 4 e-/V(-66ts---qH( ._ 1 )..ocicolvocr pc:forming L4 ?A•ork•nlysclf. , ,:.•'.:: :. ..**.....** .... I : Proprietor and ItarC no onc working in any capacity. .._..... c:nploycr providing Isorkcrs' c..)rilperl.s.ation ror my csruployccz wolLing Ofl Phonc Sta!C. :s.y.:ran.:c Company: a:n proprietor, gcncral controctor, or h9mcolvncr (cif* onc) and have ItI(cd the Contro...tcrs t•,:!ow who lave the follobkint workcrs' comp4suocion policy: Corn;lany c: Phonc o■ dzirc:s: Com-u.. Policy: qtr. Co: y na nil • Construction Specialties • Stoneham. MA 02180 Cor.:pany; L- 1, shccts u nccc..ssary. Pltonc Statc: 617 -_-_4 Le LI ( City _ State: /126,0 C-- 00 /-17—b04,74 5rc coverage aS required undcr Scction 23A of MGL, 152 can !cad to the implementation c.( 4 pertaltics of a runt up to 51,503.00 and / or onc ycari' imprisonment as well as civil peria! tics in • I:1: form "STOP WORK, ORDER" 'ar1,1 1 fwe of SI00.00 a daY acairtst mc. .1 tmdcrstand that a copy e( r.uy foni-arded 10 the Officc or Invcstication of thc DIA for eovcracc vcrification., 1.1:e pa:ns and penalties o( T ( F- ( A / Datc: 0 • 0:!)"" (!.) not writ,: in t!..is vca — to In completed by city or to;s1t c Pcrmit Dept: Map #: Lot #: Unit*: Street #: Street Name: Street) n111 #: .r or ---- ••O•o•— Permit#: t: l�ui #dine � gip eta Document Type: (J' an) (Plot) �Pe ) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PE EKED DEC 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 2010 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit thousand valuation or.,any portion they ofr. iBa min/MIA/1A- Property Address: 3 Lot v t ( S+ lsi Own $ r -ofRecord: ,4& iOd Assessors Map # 7(9 Lot # =73 Type of Occupancy: New: V Renovation: Replacement: Plans Submitted: Yes No Installing Company Name:Aidi t e Cku c; (.t'tkt✓ t k c 6 Company Street Address: (3 co1c'v\ ' 8,i- City: e,(,1c,w10" -e _ Zip: 03b1 Company Phone Number =L. Estimated Cost: $ Ir46k0 Indicate total number of units in the applicable box below Family IN418, Basement 0 2nd Floor 3rd Floor 0 x C Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil if Generators Other: Basic Building Code Commercial Basement $ U. to ° o 11., N °o U- M Roof _ O 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other;CJS r-; "er 44? if " 0154( ( v?if4�t1- V 1 fit, ,t4(y .clams iJctV-. 60 i'y biiivat 5 Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Signature: r /1/11 e) `t %1.0∎hte, Print Name: Type of License: I�089,,8 License #: This Section for Offical Us Only Permit fee: aR-t Issued By : Revised 12/31/09 Receipt #:29, ( h Date Received: r pproved Date: Received by: Permit Number: 10 .- 13S1 Ro CERTIFICATE OF LIABILITY INSURANCE 7/i4�2o10 ) 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 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 The Driscoll Agency, Inc. 93 Longwater Circle P.O. Box 9120 Norwell MA 02061 CONTACT NAME: PHONE FAX ALo,Ext):781 681 -6656 (A/C,No):791- 681 -6686 ADDRESS: jbd @driscollagency.com PRODUC R CUSTOMER ID #: 5702 INSURER(S) AFFORDING COVERAGE NAIC # INSURED Architectural Fireplaces of New England, Inc. 15 Colonial Dr. East Hampstead NH 03826 INSURER A: Peerless Insurance Company 24198 INSURERB:The Employers' Fire Ins Co. INSURERC:ACE Property & Casualty Insurance 12/30/2009 INSURER D : EACH OCCURRENCE INSURER E : DAMAGE TO RENTED PREMISES (Ea occurrence) INSURER F : COVERAGES CERTIFICATE NUMBER: 1927855359 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 INSR ASSy R BA POLICY NUMBER POLICY (MM/DDIYYYY) D (MD/YYYY) LIMITS A GENERALUABILITY COMMERCIAL GENERAL LIABILITY X OCCUR CBP8365065 12/30/2009 12/30/2010 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100, 000 CLAIMS -MADE MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L —I AGGREGATE LIMIT POLICY X PRO JECT - APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 LOC $ B B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS F131808033 - MA Auto 7530190680003- NH Auto 12/30/2009 12/30/2009 12/30/2010 12/30/2010 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X PROPERTY DAMAGE (Per accident) $ X X Coll w/ Waiver Ded $500 Comp Ded $500 A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CU 8669202 12/30/2009 12/30/2010 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 DEDUCTIBLE RETENTION $ $ $ c WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS Y / N N / A NWC C45865873 12/30/2009 12/30/2010 X WCSTATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $1,000,000 Y E.L. DISEASE - EA EMPLOYEE $1,000,000 below E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Notice of cancellation provision is 30 days, except 10 days applies for non - payment of premium. CERTIFICATE HOLDER CANCELLATION 30 Town of Lexington, MA 1625 Massachusetts Avenue Lexington MA 02420 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE laasit'l so ACORD 25 (2009/09) O 1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD tel:, idle_ die-4 A<t- Map #: Lot #: Unit #: Street#: itreet Name: _‘, %. j,f Z-.1911/A/ /1-1�1" rreet Unit #: ernit t ##: Department: Butidm {a:1e, trnent Type: (tan) (Plot. %-7 -6 Perm TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: (4_ kcd31a wn Rie Owner of Record: /\ iv ,'n yam ar i fl`I-O Assessors Map # Lot # /of /) Type of Occupancy: i(51 icier) GE New: Renovation: Replacement: X Plans Submitted: Yes No j( Installing Company Name: Jo,M& De tj Oa j Company Street Address: 1---1.7 dJ Cj k Ave_ City: Company Phone Number: (Q (1 -a UI 14 363 MA-- Zip: 0145 Estimated Cost: $ 174o60 — Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement] °o `-' o N 3rd Floor Roof 1 Ground* 1 Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit 1 Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: hOj krI0l' •ink J Basic Building Code Commercial Basement] Joold isl- 2nd Floor o u- co Roof" Ground* Generators Draft Inducers Oil fired Equip 1 Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: n aT _ ttiOr l.5 0� dit PLIti lUIVY Type of License: License #: W 11(e rnC08 ht y P • femme: /� This Section for Offical Use Only Permit fee: By : Date Received: 7//9/10/0 Revised 12/31/09 Approved Date: .* v e Received by: Permit Number: �D - `77 / The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (Business /Organization/Individual): TA-(44,'.r t e v a 14. y F J f -L eb Address: /77 (M-A is Ave- Y t b e K Cf t a-v City /State /Zip: P t-°,3 41-4 oa 15°( I -c) Phone #: 617-9 b t 3 1 3 Are you an employer? Check the appropriate box: 1. 121. I am a employer with 13 6 employees (full and/or part- time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a general contractor and I have hired the sub - contractors listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.t 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12. ❑ Roof repairs 13.ta Other t F4/V by i lj l " *Any applicant that checks box #1 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. :Contractors 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: A L if t YQ S A- 4e Policy # or Self-ins. Lic. #: e F it g 3 00 (7 00 Expiration Date: Job Site Address: 1,10 (, AU C) Attach a copy of the workers' com ensation policy declaration page (showing the policy number and piration 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. City /State /Zip: I do hereby ce nder the p s an p alties of perjury that the information provided above is e and correct. Signature: /44eki C Date: i// q/, O ci '7 qCP iii - 63 S Phone #: 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: The Official Website of the Office of Consumer Affairs & Business Regulation (OCABR) `Division of Professional Licensure Mass.Gov Home State Agencies State Online Services ry Home > Division of Professional Licensure ....... ............................... Check A Professional License By the Division of Professional Licensure LICENSEE Name: THOMAS DOHERTY Business: JAMES DEVANEY FUEL CO.,INC. MP# 12909 BILLERICA, MA NEW SEARCH * *This Licensee has additional Licenses, click here to view them.** Licensing Board: PLUMBERS �. GASFITTERS License Type: PLUMBING CORPORATION License Number: 2563 Status: CURRENT Expiration Date: 5/1/2012 Issue Date: 10/10/2003 Exam Date: School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Monday, July 19, 2010 at 9:38:15 AM. © 2007 Commonwealth of Massachusetts 1 Mass.Gov SEARCH Office of Consumer Affairs [Search ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATED INFO Disclaimer Regarding Website License Searches Enforcement Process Glossary Help on License Search More... Site Policies Contact Us Site Map DO� PART F P LIC Oil Bumer Technician Certificate Number: BU 026112 :,,07109/2010 Tr. no: 6299.0 Restricted: 1 JAMES M GILBER'. 34 HOYLE ST NORWOOD, MA 0206 Commissioner'{ COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE OF ELECTRICIANS REGISTERED MASTER ELECTRICIAN ISSUES THIS LICENSE TO GILBERT ELECTRIC JAMES M GILBERT 34 HOYLE STREET NORWOOD MA 02062 -3227 10194 A 07/31/10 303811 LICENSE NO. EXPIRATION DATE COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE OF ELECTRICIANS AS A REG JOURNEYMAN ELECTRIC/ ISSUES THIS LICENSE TO JAMES M GILBERT 34 HOYLE STREET � NORWOOD MA 02062 -3227 19573 E 07/31/10 303810 LICENSE NO. EXPIRATION DATE SERIAL NO. n i :aagwnN rn K (� O a CD CD O • N N N 01 I.) w p D0 - -f1 O EY 73 n OD co 1 �^ h cp Illllllllrotogs''� . �I��I;IIIIIIIIIIIIII�11 IIhIII� COD O O 1 0 n N. 6 0. n 0 DZ co O 0 a O 0 m y 0 ii 0 0 :ol pa ;oi.gsaa 01 Board of Building Regulations and Standards ConsttuttiOn.Supervisor License License: CS 302 ReStrictedbx WILLIAM+ 86 MINK WILMING Co mmissioner Expiration: 10/25/2011 Tr#: 8658 P 7, 0o MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) IN-e)( 1940r) r) ,Mass. Date J UJ y 30 /0 Permit # Building Location ti a kedQe sq tAi n AV' ner's Name Iv it) y QAr) a nc4o Owner Tel# f V-- a - 1474,15' Type of Occupancy re.54-clenoe New ❑ Renovation ❑ Replacement LX. FIXTURES Plan Submitted: Yes ❑ No 1( i Installing Company Name JO./ A4 Address 17 W J i Ave Nest)`Eon, NPr OW46 9 Business Telephone # 1.0 t 1 " q1-0 LI ^ 3 1 Name of Licensed Plumber Check one: Certificate Corporation ❑ Partnership ❑ Firm /Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have c ecked ,des, please indicate the type coverage by checking the appropriate box. A liability insurance policy t Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Law By Title City /Town APPROVED (OFFICE USE ONLY) Signature of`Licensed 'lumbe Type of License: Master yr License Number 3 El la.qo ,l tJ7!�� DAD (y 4G t^g WATER CLOSETS KITCHEN SINKS LAVATORIES BATHTUBS SHOWER STALLS DISHWASHER DISPOSERS LAUNDRY TRAYS J WASH MACH CONN HOT WATER TANKS ITANKLESS SLOP SINKS FLOOR DRAINS GAS TRAPS URINALS DRINKING FOUNTAIN AREA DRAIN WATER PIPING ROOF DRAINS BACKFLOW PREV_Lbp f OTHER FIXTURES: SUB -BSMT BASEMENT x 1ST FLOOR 2ND FLOOR 3RD FLOOR 4T" FLOOR 5T" FLOOR 6T" FLOOR 7TH FLOOR RT" FT.00R Installing Company Name JO./ A4 Address 17 W J i Ave Nest)`Eon, NPr OW46 9 Business Telephone # 1.0 t 1 " q1-0 LI ^ 3 1 Name of Licensed Plumber Check one: Certificate Corporation ❑ Partnership ❑ Firm /Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have c ecked ,des, please indicate the type coverage by checking the appropriate box. A liability insurance policy t Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Law By Title City /Town APPROVED (OFFICE USE ONLY) Signature of`Licensed 'lumbe Type of License: Master yr License Number 3 El la.qo ,l tJ7!�� DAD (y 4G t^g J6„ die-4 zitet y°/ Map #: • Lott Unit #: Street##: 7 � 4 � treet Name: /� i�`/ l greet Unit #• Oepartment:«�ici��n Document Type: t f''[ at I Ins TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x-211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property. Address: L ;13e Owner of Record: tYWCAA,c, bne Assessors Map # i 7 Lot # � Type of Occupancy: Re) New: Renovation: Replacement: --- -Plans Submitted: Yes r Installing Company Name: )< e'1 <\ c,r SnIlt,` Company Street Address: < f 8 c, rr s S City: Company Phone Number: 1 1 -'D -1- g b�1 C3 No v r1 \ n on Zip: 0) 03 Estimated Cost: $ Indicate total number of units in the applicable box below 1& 2 Family E .) °0 `` 0 0 Roof Ground* Air Handling Units / Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement] o it a ,- 2nd Floor 3rd Floor Roof ti c O 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that ail mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexijton: natu 4-- e-,en ��c \c,n: Print Na e: per. Type of License: 4Y� 1 License #: This Section for Offical Use Only Permit fee:(, C .v+ Issued By : Revised 12/31/09 Receipt # Date Received: (/ c;‘)f0 Approved Date: Received e r1cf7Permit Number: to - S J,/itiL/J A le- die-4 721,1 Map #: Lot #: Unit #: Street #: g street Name: L-000(Sr__ /41/ greet Unit #: w Oepartment: 13u'Wing i) cement Type: j ELi} ('!f?t TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 - 862 -0500 x -211 Fax: 781 -861 -2780 Building Location: 22 Locust v Owner's Name: Robert Pressman Map # RD Lot # ? Type of Occupancy: Residential New: Renovation: Replacement: © Plans Submitted: Yes No Installing Company Name: White's Plumbing & Heating, 1 LC Company Street Address: 687 Fellsway West City: Medford, MA Indicate total number of units in the applicable box below Zip: 02155 `74C-/ 396 ke77 Basement I O _p O O p N O _O O (7 Roof I "O C 0 0 Air Handling Units Heating Zones Evaporative Coolers Heat Pumps Range Hoods Refrigeration Units Sprinkler Connection Sprinkler Heads Sprinkler Hose Conn. Ventilation Fans Boilers -Gas Boilers -Oil Furnaces -Gas Furnaces -Oil Process Piping Generators No Vent Heaters Steam Kettles Duct Coils Zip: 02155 `74C-/ 396 ke77 Describe Project: `Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and 'installation performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the ICC Mechanical Code, an all laws/bylaws/regulations of the Town of Lexington: SigrSature: Brian White Printed name: Master Plumber 13405 Type of License License # Permit fee: This Section for Official Use Only 1 Receipt #: 1 Date Receivedd,L/1O Received by: 1 Permit #49.33.7 � Inspector: G�� ` tt /JO Approved Date: Rev 8/5/08 626 vat 146:2,0i6 Basement L O it r❑ 'a O O N .i O 0 ii v ch Roof* f O c c O 0 Fire Suppression Draft Inducers Kitchen Equipment Pool Heater Pumps Radiant Heat Radiant Heat Incinerators Steam Generators Baseboard Heat Radiators Kick -space Heaters Hydro Air Systems Direct Vent Fireplace Roof Top Units Central Air Conditioners Describe Project: `Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and 'installation performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the ICC Mechanical Code, an all laws/bylaws/regulations of the Town of Lexington: SigrSature: Brian White Printed name: Master Plumber 13405 Type of License License # Permit fee: This Section for Official Use Only 1 Receipt #: 1 Date Receivedd,L/1O Received by: 1 Permit #49.33.7 � Inspector: G�� ` tt /JO Approved Date: Rev 8/5/08 626 vat 146:2,0i6 diza //tEClL Map #: Lot #: Unit #: Street#: 'treet Name: Treet Unit #: 'ermit #: o� D Department: Building i)w urnent Type: `PEz.n) tPlot) t. TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781-862-0500 x -211 Fax: 781-861-2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address L1 t v ; A Owner of Record:AO Vie; I~ 7 c-;,, n I nr\ Assessors Map # 402- Lot # ,2-o2.6 Type of Occupancy: c`. /171,, r New: Renovation: Replacement: Plans Submitted: Yes No Company Name: 4.76. j ;,e Company Street Address: 11" AL l► - t 1? City: ,( II,: -1 z. I Zip: CY (-) a Company Phone Number: -7d / - / 7 j Estimated Cost: $ Indicate total number of units in the applicable box below Family iNi 1 &2 Basement 0 N oo � 3rd Floor o � _. 0 Air Handling Units d"l �- reArgiLi Issued/ /E " ^' ... Approved Dater /Q' Permit Number: 60 �'J/ Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement 0 u- in' 0° u a N oo i c,, Roof b o 0 Generators d"l �- reArgiLi Issued/ /E " ^' ... Approved Dater /Q' Permit Number: 60 �'J/ Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: This Section for Offical Use Onl Permit fee: I Receipt #: I Date Received: ' I Received by: Describe Project *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: 1 certify that 1 have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws/regulations of the Town of Lexington: iiii4C 193-Mk' Cificl °I ci_ Signature: Print Name: . f i ; , Type of License: License #: d"l �- reArgiLi Issued/ /E " ^' ... Approved Dater /Q' Permit Number: 60 �'J/ Rev 1/;/ Jit,(A 7//w Map #: Lot #: Unit #: Street#: 'treet Name: Treet (nit #: 0 �©GUe/,7 _7 _r Oepartrnent: Bui i Doettment Type: (Nan) (Plot) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 5 Lo W LL : S'"i Owner of Record: 6 �. t%r'9%1/Ni Assessors Map # 2-0 Lot # I/3 Type of Occupancy: fib' New: Renovation: '✓ Replacement: Plans Submitted: Yes No Installing Company Name: 43 1, /, / L/C Company Street Address: /7) 6Y ,lM SAC ty: /n JVdJ ' Zip: CZ /%A Company Phone Number: 7 0' ?/h 7 Estimated Cost: $ 5 o Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement ° o u- N; 2nd Floor I 3rd Floor Roof 0 Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: Basic Building Code Commercial Basement I r ° o u- N; 3`d Floor I Roof* 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment's being placed outside of the footprint of the, building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equi ment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Cc nmissi n. All equi ment s subject to Lexington's Noise By -Law: certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under t • rmit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Bui ing C e International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: / Zo -ati_ez vet le4s-i&-Lp6-6 /2.6---7v Print Name: Type of License: License #: Signa This Section for Offical Use Only Permit fee: Issued By : Re '77/ oved Date Permit Number: iihkelp _ � '? x Revised 12/31/09 ,e„I- Cf ztif 11 Received by: Received: Jit•(-A /oar- 1./661 �e- Map #: 3 . Lot #: —2. 7 e) Unit #: Street ft: _ 6 'itreet Name: /el tv� �- >£reet Unit #• Department: Burltimg Document Type: f pE� at) 911 era®` TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781-862-0500 x -211 Fax: 781-861-2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # Property Address: 7-1 t, Len, --e L 5 l Owner of Record: P� j� lC �o� Assessors Map # Y1 Lot # \ 7 G Type of Occupancy: 5-7e,i New: Renovation: Replacement: t/ Plans Submitted: Yes No Installing Company Name: k, tit 1M -e cwiA w v"(.ak Th-C Company Street Address: G g Gv'to f—E- Aif City: ?kJ/ � , Zip: a/e33 Company Phone Number: 7P - 2-z' 2 5/4rc/ Estimated Cost: $ .,574 Indicate total number of units in the applicable box below 1 8c 2 Family Basement Joold ,s1. °o u_ N °o J c Roof 1 c 0 o Air Handling /Hydro Units Evaporative & Refrigeration Coolers Heat Pumps Range Hoods Vented to Exterior Central Air Conditioners Combustion Air Nentilation Fans Energy Recovery Ventilators Furnaces- Oil Other: c:45 r‘. „,_,.. „ k- Basic Building Code Commercial c E a) co (0 0 0 LL 0 0 EL -o N 0 0 M 0 0 1' a 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & E,diaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By- w: 4,5 —4. e/Ace I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws/regulations of the Town of Lexington: Workers' Compensation Insurance Affidavitrequir for all mechanical submissions l� �L j✓7'fie Sian - ure: Print Name: Type of License: X23 -5 Pg 5-75 License #: This Section for Offical Use Only Permit fee: 114 -- Issued By : Revised 8/4/10 AC Receipt #: cl De) i Date Received: )DJ� -)/ J D Approved Date: , ( Permit or Alteration Number: Received by: J,4-4 Map #: Lot #: Unit #: Street#: •itreet Name: ;greet Unit #: }department: B«3lcii -�G t)c nment Type: (P [L.n. (Plot er ) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: A-4-- Owner of Record: Assessors Map # Lot # Type of Occupancy: New - '1Zenovation: Replacement: Plans Submitted: Yes No Installing Company Name: 2. -6 Company Street Address: Company Phone Niszjen Specialties — estimated Cost: $ lc) Stoneham 1n ica o a ni i of units in the applicable box below City: Zip: Basic Building Code Commercial 1 &2 family Basement °o 2 "d Floor I °o II M Roof °c o 0 Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: Basic Building Code Commercial Basement I o L °o U. N °o U.. M Roof* I _ 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: -17,11 Signature: Print Name: Type of License. C5, Li License This Section for Offical U nl Date Received: 7/7371--0 Approved Date: Permit fee: 17t . (',0 Issued By : Revised I2 /3I /0 Receipt #: ,7(1� 74/3/0 y Received by: fj Permit Number: ,f_AA iday Map #: Lot #: Unit #: Street#: 'treet Nome: j 2--////2 Treet Unit #: '"',unit #: /: Oepartrnent: 3 «3lclan Document Type: (rf"x2t II !c?t TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 - 862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 4 Maguire Road Owner of Record: Curis Assessors Map #Lot # Type of Occupancy: New: Renovation: X Replacement: Plans Submitted: Yes No Installing Company Name: Environmental Systems, Inc. Company Street Address: 6 Howard Ireland Drive City: Attleboro, MA Zip: 02703 -4612 Company Phone Number: (508)226 -6006 Estimated Cost: $164,000.00 Indicate total number of units in the applicable box below Basic Building Code Commercial 1 & 2 Family Basement °o LI _ °o u- N °o u -o co Roof Ground* Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators 3 Other: Ductless Split Furnaces- Oil Generators Other: Basic Building Code Commercial Basement o u_ 7, ,- 2 "d Floor g u_ E M Roof* Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners 3 Other: Ductless Split Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Ma sachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of gton: !ure: s S. Baldasaro Refrigeration Contractor Print Name: Type of License: 105129 License #: Permit fee: /9 Issued By : Revised 12/31/09 This Section for Offical Use Onl Date Received: f6 /i6) Receipt #:61 3 Received by: C Approved Date: /dbp Permit Number: 0-/N1 • • • ✓Ace ../74asach aea D PARTMENT OF PUBLIC SAFETY Refrigeration Cbnfractor• License Number: Res JAMES Si. SAIDA 50 BROOK ST NATTLEBORO, MA 105129 0 Tr. no: 854.0 MENTAL. SYSIEMS.INC Coinmrss!or er • • J 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Environmental Systems, Inc. Address: 6 Howard Ireland Drive City /State /Zip: Attleboro, MA 02703 -4612 Phone #: (508)226 -6006 Are you an employer? Check the appropriate box: 1. J I am a employer with 70 4. ❑ I am a general contractor and I have hired the sub - contractors listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.t 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] 2.❑ 3. ❑ employees (full and /or part- time).* I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] I am a homeowner doing all myself. [No workers' comp. insurance required.] t work Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13. Other HVAC Mechanical *Any applicant that checks box #1 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. Contractors 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 Employers Insurance Company Policy # or Self -ins. Lic. #: MCC20002180120 Job Site Address:4 Maguire Road Expiration Date: 01/01/2011 City /State /Zip :Lexington, MA 02421 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 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 certjfj' under the ins ort Signature: Phone #:(508)226 -6006 nd penalties of perjury that the information provided above is true and correct. Date: 10/4/2010 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 Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: t ,ienus: 'IU3a3 ACORDTM CERTIFICATE OF LIABILITY INSURANCE 01/05/2010 TYPE OF INSURANCE 'PRODUCER & Shepley PO Box 549 Providence, RI 02901 -0549 401 435 -3600 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Environmental Systems, Inc. 6 Howard Ireland Drive Attleboro, MA 02703 -0037 INSURER A: Peerless GENERAL INSURER 8: Associated Employers Ins Co /AIM 8746208 INSURER c: Houston Casualty Co 12/31/10 INSURER D: $1,000,000 INSURER E: DAMAGE TO RENTED PREMISES PREMISES (Ea occurrence) COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD`L INSRC TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM /DD/YY) POLICY EXPIRATION DATE (MMIDD/YY) LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY 8746208 12/31109 12/31/10 EACH OCCURRENCE $1,000,000 X DAMAGE TO RENTED PREMISES PREMISES (Ea occurrence) 000 CLAIMS MADE X OCCUR MED EXP (Any one person) $10,000 PERSONAL & ADV INJURY $1,000,000 $2,000,000 $2,000,000 GENERAL AGGREGATE GEN'L AGGREGATE LIMIT APPLIES PER: POLICY n 110 n Lac PRODUCTS - COMP /OP AGG 7 A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS Drive Other Car 8746008 12/31/09 12/31/10 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 X BODILY INJURY (Per person) $ _ X BODILY INJURY (Per accident) $ X X PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ —1 OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESS /UMBRELLA LIABILITY OCCUR n CLAIMS MADE DEDUCTIBLE RETENTION $ 10000 8746408 12/31/09 12/31/10 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 $ $ $ B WORKERS COMPENSATION AND LIABILITY ANY PROPRIETOR/PARTNER /EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below MCC20002180120 01/01/10 01/01/11 X J TOW STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1,000,000 C OTHER Professional Liability H71016354 01/01/10 01/01/11 $2,000,000 $5,000 Ded. Per Claim DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS RE: HVAC /Control Work CERTIFICATE HOLDER CANCELLATION 10 Days for Non - Payment Town of Lexington 1625 Massachusetts Avenue Lexington, MA 02420 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL. ENDEAVOR TO MAIL ail DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE C ACORD 25 (2001/08) 1 of 2 #S246493/M246194 JMR © ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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).. DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 -S (2001/08) 2 of 2 #S246493/M246194 71/-e mod_ �e NJ/k_.d Map#: Lot #: o / Unit #: Street#: f 4treet Name: 7/7A 3 i� ireet Unit #: '? TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: / .4/6 M Assessors Map # Lot # Type of Occupancy: 5 /d . New: Renovation: Replacement: X Plans Submitted: Yes No Owner of Record: To d-!' /, Rif Z'eil Installing Company Name: A/ Company Street Address: C ' er� p de City: 0 I f Zip: r /4( Company Phone Number: : `" -5'24.1 X /04 Estimated Cost: $ 3 2y 04 Indicate total number of units in the applicable box below 1/W1&2 Family Basement 0 Li V+ 0 LI C N 0 Li '2 (h Roof Ground* Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil 2 &a/- Generators Other: Basic Building Code Commercial Basement $ u. _ °o u.. N _ °o ti M Roof* 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: 2 &a/- Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Ma - achusetts S a Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Le ington: 61 eer? 7 Print Name: Type of License: License #: This Sc iion for Offical Permit fee: Issued By : dAd Revised 12/31/09 Receipt #: ct Use O Date Received: 10 Approved Date: to ( /t9 fro Permit Number: (© I t 7 6 to ( y Received by:- TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781-862-0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: i'L e"M'L e- r Assessors Map # Lot # Owner of Record: <De Lex-(6 .4.70 M Type of Occupancy: o t New: Renovation: Replacement: Plans Submitted: Yes - No Installing Company Name: ho s Company Street Address: loci PI ci rtkAc.g11•eit- c_ City: 6,,y e Company Phone Number: Con - (oce Zip: O14 Estimated Cost: $ r� Indicate total number of units in the applicable box below 1 &2 Family c E CO s- 0 0 LL N 0 0 0 0 v c 2 Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement 0 0 u_ - o 0 u- N 0 0 � 0 c) Roof c 3 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws/regulations of the Town of Lexington: Signat doe s - 7D eefitt6ektrtog ? ro2 -cao, 2 Print Name: Type of License: Us License #: This Section for Offical Permit fee:„.-6- Receipt Date Received: e nI %A/ Received by: 9 L Revised 12 /31/09 of://cY) Map #: °Z Lot #: / 7 Unit #: Street#: `L ? //' street Name: _,m ,*/.. R_D :Treet (Jnit #: /1? — 27 Department: Building ()0(11.1 lent Tvpe: TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # Property Address: i P Owner of Record: 6 0(t-er (J! - lcl /K Type of Occupancy: 51 P ty' Assessors Map # Lot # i 7 New: Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: `cc ,z vAL /v — 14.0r^eo; Company Street Address: lfsl i rre-tf- / City: )crvijri Zip: Oati2.0 Company Phone Number: 751- 5-38 -68-51 Estimated Cost: $ (00, o Indicate total number of units in the applicable box below Basic Building Code Commercial 1 & 2 Family Basement 1 00 _oo N 3rd Floor Roof Ground* Air Handling /Hydro Units Draft Inducers Oil fired Equip Evaporative & Refrigeration Coolers Kitchen Vent & E *gust Equipment Heat Pumps Pool Heater Range Hoods Vented to Exterior V" Process Piping Central Air Conditioners Roof Top Units Combustion Air Nentilation Fans Radiant Heat Energy Recovery Ventilators Hydro Air Systems Furnaces- Oil Central Air Conditioners Other: Other: Basic Building Code Commercial Basement o g LL N �- L C N 3rd Floor Roof* 0 o V U` Generators Draft Inducers Oil fired Equip Kitchen Vent & E *gust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: 1 s' r4-1_1,--1,9 P LEclrj-1 c S'r©L/ VEisr y fl 9}--/ r?3 (Tr t I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Workers' Compensation Insurance Affidavit re uired r all mechanical submissions yn License #: Sionat Print Name: Type of License: This Section for Offical Use Only Permit fee: 3o.A Receipt #: c��tSi Date Received: PI Av Issued By : Approved Date: / or Alteration Number: Ii /!0 JO - L3�( " ILA //0 Received by: /c. Revised 8/4/10 AC J ,-/J N^�zc� �9��a fit Au Wit- Map #: Lot #: Unit #: Street#: a street Name:____________ f — 4) Meet Unit#: attrmlt #: 2 --- Department: Blithling Document Type: tPL n) (Plot} TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 34 ( c(e14 `` 01\ Owner of Record: R0 L OF C7- Assessorf Map # 33 Lot # Type of Occupancy: New: Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: Ptrc(iki {-eC1U rC( reQIaC €5 Company Street Address: Cs Colonictiw Ora City: Cast Mamps+eQ) AM Zip: 034Th Company Phone Number: (G03) -OU,).0 Estimated Cost: $ ` 000 Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement 1st Floor S u. N 3rd Floor Roof Ground* Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: D ;re c t- Uen4- F repktc e Furnaces- Oil Generators Other: Basic Building Code Commercial Basement S u_ i, 2nd Floor 3rd Floor Roof" Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: D ;re c t- Uen4- F repktc e Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexin ton's Noise By -Law: 1 r^' 4altip,, srirtelUee. g tier in r3 . C3,-ell G'o- e. 9 c :Qr . .J I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of jt xington: /im(r-- nature: -,.\USf. (sr\ fteie Print Name: Type of License: License #: Permit fee:30 Issued By : This Section for Offical Us O ly Date Received: 7p Received by: (3-L SPA sproved Date: 5A-7( Permit Number: to —.356 Revised 12/31/09 Receipt #: C 7 ACORD, CERTIFICATE OF LIABILITY INSURANCE 15 TE(MM18/2009 D FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LLABIUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. PRODUCER (781) 681 -6656 FAX: (781) 681 -6686 The Driscoll Agency, Inc. 93 Longwater Circle P.O. Box 9120 Norwell MA 02061 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED Architectural Fireplaces of New England, Inc. 15 Colonial Drive East Hampstead NH 03826 INSURER A: Peerless Insurance 24198 INSURERS:The Employers' Fire Ins 20648 INSURER C:Commerce & Industry 19410 INSURER D: INSURER E: COVERAGES THE POLICIES REQUIREMENT, THE INSURANCE AGQREGATE OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, AFFORDED BY THE POL CIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR LTR ADM INSRO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MMIDDIYY) POLICY EXPIRATION DATE (MM/DDIYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY CRP 8365065 No Residential Exclusion or limitations 12/30/2008 12/30/2009 EACH OCCURRENCE $ 1,000,000 PREMISES (E RENTED $ 100,000 X ICI-AIMS MADE Includes X OCCUR MEDEXP (Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 Coatractural Liab. GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ri-i JECT n LOC PRODUCTS - COMP/OP AGO $ 2,000,000 B AUTOMOBILE _ X X X X LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS Coll w/ Waiver- $500 101511308033 - MA Auto 753019068 - NB Auto 12/30/2008 12/30/2009 COMBINED SINGLE LIMIT acct) $ 1, 000, 000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Pm accident) $ X Comp Ded. - $500 GARAGE 2] LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC J AUTO ONLY: AGG f $ A EXCESS/UMBRELLALIABILITY X OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ To Be Determined Does Not Sit Over Automoblie Liability 05/12/2009 12/30/2009 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 3 $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER /EXECUTIVE OFFICER/MEMBEREXCLUDED? If yes. describe p`�r SPECIAL PROVISIONS below WC 005 -15 -0072 3A. States Include NA & NS & NS 12/30/2008 12/30/2009 X I TORY LIMITS I 1 ER E.L.EACHACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1, 000, 000 A OTHER _ DESCRIPTION OF OPERATIO NSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Notice of cancellation provision is 30 days, except 10 days applies for non - payment of premium. CERTIFICATE HOLDER CANCELLATION Town of Lexington 1625 Massachusetts Avenue Lexington, MA 02420 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LLABIUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Sally Driscoll /KEC - - -= r-,c'r --- = %" i -%`- ' — ..- -fic`-{ ACORD 25 (2001/08) ® ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001108) 1NS025 (0108)08. Pegs 2of2 dl-g4 \l/bc-d Map #: Lot #: Unit #: Street#: 3 J 4 Street Name: .3=reet Unit #: '<'.rmi t #: Department: ___Buildin 35 t)c c1?rent Type: (lr! n) (Plot } (Perth r TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof 0Cre+. ZCI `'n1 Property Address: (' Owner of Record: go, e Assessors; Map # 33 Lot # 026 I-1 Type of Occupancy: New: I Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: P\,rCL ec."ur +l F ;ize!ace6 Company Street Address: 15 Co(o‘iu1 6(. City: Cas-+- k cps eac, AM Zip: O3 2& Company Phone Number: (003) 30 00N Estimated Cost: $ 1, 00 6 Indicate total number of units in the applicable box below �iUS+ r Family 141& 2 Basement o° 2nd Floor 3rd Floor Roof Ground* Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement o u_ -,-.. 2nd Floor 3rd Floor Roof* = o a Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: 0,:, ,4, Vend' irzfjiate Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: Ff�zf\CIC42_ anti Uefv ' Qr\ PpiAs done % (Akers.. I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of exington: ature: G- ree 149,9 AI Print Name: Type of License: (3( 5-Pc License #: This Section for Offical U e my Permit fee: 30.00 (g l (7 Received by: I Issued By : pproved Date: S 5 0 Permit Number: to - 3S7 Revised 12/31/09 Receipt #: Date Received: Jiu(A d-tee)J j_e„ Map #: • Lot #: Unit #: Street#: street Name: 3 3 6 1 -77fx°/e t 77- . =Treet Unit r: 'ermit #: /G2 -- 35 Department:3«i1ci� i)ncliment Type: (Plan) (Plot) (Perm) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: d Owner of Record: plJ\ Assessor Map # 33 Lot # o961 Type of Occupancy: I New: V Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: Pk rC,Lt to c f -ucc.( Ft (e fa(Qces Company Street Address: (5 Co(or ia( City: C. t la tead, Akt Zip: D3ga Company Phone Number: (603) 36°" OO a° Estimated Cost: $ I, 00 Indicate total number of units in the applicable box below Basic Building Code Commercial 1 & 2 Family Basement 00 ,- c, N 3`d Floor Roof c 2 0 Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process. Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: t r rec4- ife /14' fi -ee late5 Furnaces- Oil Generators Other: Basic Building Code Commercial Basement 1st Floor 2nd Floor 3rd Floor 0 cc 4. o 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process. Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: t r rec4- ife /14' fi -ee late5 Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexin ton's Noise By -Law: i 1 N sa I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Buildinc Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexingto ; &}1/L/) 1/1(ig4 /11,1 Map #: • Lot #: Unit #: Street # 3 ,3 6 Street Name: ;Tweet Unit#: Department: Building t) itunent Type: ('Pan. (Pk 3 TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: '31{ ( Yiavr 4+ Rd u' l' Owner of Record: PUN L.a e - Assessors Map # 3.3 Lot # L Type of Occupancy: New: I Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: ArC k t C +UrOt Fr rep l o es Company Street Address: (5 (0(o c&( b(. City: C. Molls+eod Afrf Zip: C3 ' Company Phone Number: (GO SP- OO O Estimated Cost: $ 1 WHO Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement °o - 2nd Floor 3rd Floor Roof c o Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Hydro Air Systems Central Air Conditioners Central Air Conditioners Ventilation Fans Other: l rec Ve114- rre,late V Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement o u_ N r 2nd Floor 3rd Floor ° o �N LL Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: l rec Ve114- rre,late V Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject t 4 L TU I�t B Law:' I Q exi ton's . ise y- kS i /1 � ...aid Ip one ofiter. I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of exington: ,d:I_Ir A. . i4 1 I u re: 11;(\ G re e ( Print Name: Permit fee: 36, (90 AJF-. Type of License: This Section for Offical Usf O y Date Received: .11@q f j 0 Approved Date: 615—fro Permit Number: 10 — S6 License #: Receipt #: AS (5 Issued By : Revised 12/31/09 Received by: Map #: Lot #: Unit #: Street#: 4treet Name: greet Unit #: o Department: d «31d Document Type: ( I =n) fi TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit leTE: $12 ,per one thoosantr valuation or any portion =thereof rawrr,raa rm._ Property Address: 3 4 I I'Yaf reif . Owner of Record: 2ron Late2 (ons'fruch6ry Assessors Map # Lot # Type of Occupancy: New: Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: Arctilkotbrgqi Arlo l� Company Street Address: / Co/6^ ;a/ Ur City: E. geiyik to/ Zip: 0782_6 Company Phone Number: 66 3'ul 0 °Z o Estimated Cost: $ /NTO Indicate total number of units in the applicable box below Basic Binding Code Commercial 182 Family Basement 1st Floor 0 0 a N 3`d Floor Roof Ground* Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: Dil 4Ve.,-V 6.14.# Basic Binding Code Commercial Basement 1st Floor o o LL N LL M Roof 0 o 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed oJ.idc, of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may requ r'e ttructural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: lien a...a Ye." 04 a G/4e R - CA_ / SOY I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed ,j- r the permit issued for this application will be in compliance with all pertinent provisions of the lassachu ett State Build exin// Sgn= ure: Print Name: Type of License: /i /&7s 9 License #: This S ection for Offical Us Permit fee: 30, Oo Issued By : Revised 12/31/09 Receipt #: 9 $37 Date Received: 23 s '' y Received by: -- Approved Date: Permit Number: to-- g S3 y A °� CERTIFICATE OF LIPI ILITY INSURANCE 7/14/2010 '""'' HOLDER. THIS BY THE POLICIES AUTHORIZED THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANt CONFERS NO RIGHTS UPON THE CERTIFICATE CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATI' /SLY AMEND, EXTLND OR ALTER THE COVERAGE Ai-FORDED BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must 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 The Driscoll Agency, Inc. 93 Longwater Circle P.O. Box 9120 Norwell MA 02061 CONTACT NAME: PHONE FAX (A/C No Ext):781- 681 -6656 (ac,No):781 681 6686 E-MAIL ADDRESS:- ibd @driscollagency.com PRODUCER CUSTOMER ID #: 5702 INSURER(S) AFFORDING COVERAGE NAIC # INSURED Architectural Fireplaces of New England, Inc. 15 Colonial Dr. East Hampstead NH 03826 - INSURERA:Peerless Insurance Company 24198 INSURERB:The Employers' Fire Ins Co. INSURERC:ACE Property & Casualty Insurance 12/30/2009.12/30 INSURER D : EACH OCCURRENCE INSURER E : DAMAGE TO RENTED PREMISES (Ea occurrence) IR!SURER F : ES CERTIFICATE NUMBER:192785�359 RFVISI[)N NIIMRFR• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE B'E f( Si!ED TO 1HE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION t + ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORD, 3D BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH PCL ;IES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID OLAIMS. INSR LTR TYPE OF INSURANCE- ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM /DD/YYYY) LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL X LIABILITY OCCUR CBP8365065. 12/30/2009.12/30 /2010 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100, 000 CLAIMS -MADE MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 7 POLICY X JEC LOC PRODUCTS - COMP /OP AGG $2, 000, 000 $ B B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS FB1E08033 - MA Auto 7530190680003- NH Auto 12/30/2009 12/30/2009 12/30/2010 12/30/2010 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 BODILY INJURY (Per person) $ X BODILY INJURY (Per accident) $ X PROPERTY DAMAGE (Per accident) $ X Coll w/ Waiver Ded $500 Comp Ded $500 A X UMBRELLA LIAB EXCESS LIAB X OCCUR. CLAIMS-MADE CU 8669202 ,12/30/2009 12/30/2010 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 DEDUCTIBLE RETENTION $ $ $ C WORKERS COMPENSATION AND EMPLOYERS' UABIUTY ANY PROPRIETOR /PARTNER/EXECUTIVE OFFICER /MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS Y / N N / A. NWC C45865873 12/30/2009 12/30/2010 X WCSTATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $1,000,000 Y E.L. DISEASE - EA EMPLOYEE $1,000,000 below E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Notice of cancellation provision is 30 days, except 10 days applies for non - payment of premium. ERTIFICATE HOLDER Town of Lexington, MA 1625 Massachusetts Avenue Lexington MA 02420 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. - HOP!ZEDRE?+RESENTATIVE ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD J-AA tale- 7/1-e-t- \AC-4-J Map #: 3 3 Lot #: Unit #: Street#: Street Name: __i,e •Treet Unjt #: Department: Building, Document Type: (Yta1 (Plot) P:f don e t.),1 TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 -862 -0500 x -211 Fax: 781 - 861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # 1067- 192_ NO ( AA vnf Property Address: l iarce+� I Owner of Record: (o( C-' G Type of Occupancy: 12 e n C Plans Submitted: Yes No Assessors Map # 33 New: Renovation: Lot # (-1 Replacement: t�C )rCL Installing Company Name: - rck V ; rei ta LeS Company Street Address: Co (00(-(4,( C. City: C. a!15Lead ' Zip: 03426 Company Phone Number: 2O 3 ` ()Oa() Estimated Cost: $ (, 006 Indicate total number of units in the applicable box below Family Alt,. Basement 1St Floor 2nd Floor 0 LI M Roof Ground* Air Handling /Hydro Units , Permit or Alteration Number: Evaporative & Refrigeration Coolers Heat Pumps Range Hoods Vented to Exterior Central Air Conditioners Combustion Air Nentilation Fans Energy Recovery Ventilators Furnaces- Oil Other: fl =, -ec+ Ue!t4 gas ; t.ef (act Basic Building Code Commercial c a) E U) N a) `o 0 U- , `o 0 N 0 0 U- (U ) 0 0 c 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & E>baust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State uilding Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Workers' Compensation 'davit reg i'Al for I mechanical submissions usf t r &ree Print Name: Tvoe of License: License #: This Section for Offical Use Only Permit fee: 30.07 Receipt #:S Date Received: 11 /j //o Received by: Issued By : _ Approved Date: Il 1( , Permit or Alteration Number: Revised 8/4/10 AC Map #: Y 3 • Lot #: - Unit #: Street#: street Name: 41-'/E' °T 7— /114E. ;Treet Unit#: Department: Building Document Type: ( ?[Ltali ec(ctc.t orj . f i C bu 1 TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 er5 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a Property Address: SL-11 (Aarl'L4+ Assessors Map # 33 Lot # building permit? YES # 1-0v i5 - NO Uni4-`g Owner of Record: Cl\ (^06)-e Type of Occupancy: Ve5Cdene-e New: Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: rJt t - (.) ra l rt re (Ct te5- � 0 Company Street Address: CviU ,\lci( b�', City: `�'�C�Mp t?4.r� V(4 Zip: ' 64 Company Phone Number: 6'263 _ 36d. 00 0 Estimated Cost: $ -O Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement 1 1st Floor 2nd Floor 3rd Floor Roof 2 CD Air Handling /Hydro Units Draft Inducers Oil fired Equip Evaporative & Refrigeration Coolers Kitchen Vent & Eaust Equipment Heat Pumps Pool Heater Range Hoods Vented to Exterior Process Piping Central Air Conditioners Roof Top Units Combustion Air /Ventilation Fans Radiant Heat Energy Recovery Ventilators Hydro Air Systems Furnaces- Oil Central Air Conditioners Other: byre CA-. V.A* 94� Other: "Fir ?06 ce J Basic Building Code Commercial Basement 1 1St Floor 2nd Floor 3rd Floor Roof* c o 6 Generators Draft Inducers Oil fired Equip Kitchen Vent & Eaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: if any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Workers' Compensation nsurance Affidav equirehd for all mecq anical submissions Print Name: Type of License: License #: This Section for O ical Use Only emit fee: ,i.00 Receipt #: Issued By : Revised 8/4/10 AC Date Received: ih7.1_ Ito Approved Date t71] Received by: oz._ Permit or Alteration Number: tQ. 123:2 J'hA Z)/z-eid-- Map #: Lot #: Unit #: Street#: 7 57 'treet Name: /11 Al 6 T /Q,D ;T eet Unit #: ' ,tram #: Department: t) w nment Type: (Plain' (Plot (Perm TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof 750 tr H-• Property Address: Assessors Map # New: Renovation: Lot # Owner of Record: Type of Occupancy: Replacement: Plans Submitted: Yes No Installing Company Name: Vi r i 4--A • C _ I n c Company Street Address: j es- yvio, jr,„.3 City: 12 4),, h Zip: 0-apt ' Company Phone Number: (str 964- c'?.& Estimated Cost: $ kitlo . Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement S 2nd Floor 3rd Floor Roof ,fpunoJo Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent &`Exhaust Equipment Evaporative Coolers Pool Heater Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: Y Basic Building Code Commercial Basement 1st Floor 2nd Floor 3rd Floor Roof* Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent &`Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: 1 Este, RI`e�nrn 7J'tor \c r' ri ? d tc?s�S e I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above a • .' • • is true and accurate to the best of my knowledge, information and belief, and that all mechanical work an ' ' ' stall . ' • ns performe • nder the permit issued for this application will be in compliance with all pertinent provisions of the M ;Letts Sta 'Building ode, the International Mechanical Code, and all laws /bylaws /regulations of the Town of COn4t,Le4iol Type of License: License #: This Section for Offical Use Onl Permit fee: Issued By : Recei Date Received: 3 /2 •& Revised 12/31/09 s'l Received by: /d2S Or, pproved Date:�� g 2 e l7 Permit Number: d Map #: 3 Lot #: 3 4 / Unit #: Street#: 3 street Name: 777/C5- 5 g=reet Unit #: '°rant #: /7.767 €department: B «iIciink, DOCAtrnent Type: i Perrna.� TOWN OF LEXINGTON ENTERED 6C APPLICATION FOR MECHANICAL PERMIT 5 Mg 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -21.1 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 34q, %%%Sd auS // °e Owner of Record: %)he- Sacco Assessors Map # /3 Lot # SCI Type of Occupancy: pees) i/' New: Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: Mid-kt,,,1 Q /U/n' lk75 -�i>ic J i C Company Street Address: (3/ (...5Y-eGQm6, i -it City: ms'k,2_0 Zip: 01 gd f Company Phone Number: q''')? y 5-3—S-70? Estimated Cost: $ Indicate total number of units in the applicable box below 1 &2 Family Basement 1St Floor o u. ccv 3rd Floor Roof c ' o Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: g.3 g�, ,3c,i'c2'- / Basic Building Code Commercial Basement o u- -a., 2nd Floor 3rd Floor oo ce c ' o Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: / /Wit` &As' pez,,t; 0 L a Ait5 cbx, t. she f Ivi4.. zi - has E/ //A-eL, 3 e Cam¢ <Sc �'£ - 2� F"2 lG ST-efr j2 7/ I certify that I have th in the above applica and installations pe Massachusetts Stat �egcington; 7 thority to make the foregoing application and that all of the information I have submitted (or entered) s true and accurate to the best of my knowledge, information and belief, and that all mechanical work ed under,. , permit issued for this application will be in compliance with all pertinent provisions of the 41il.i g. `•de, the International Mechanical Code, and all laws /bylaws /regulations of the Town of ignature. z,ed6-6. m -PioNtr- Print Name: Type of License: License #: Issued By : Th.c Section for Offical Use Receipt #- 07‘,5-50 ate Received: ill '/r /( I Received by: � Approved Date: / Permit Number: ditil /6 /d — //V, 408 C1641.. r JiixA dieo 7)Le_ Map*: L..._. Lot #: Unit #: Street#: Street Name: 2 51 5- =rieet Unit#: -';rnait 4: Department: Building t)cntmeiit Type: (Pk.n) (Plot 1 TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # Property Address: % O %h rtSS v v Owner of Record: Pj(r �1� ✓' c Assessors Map # o9\ Lot # Type of Occupancy: New: Renovation: Replacement: 1- Plans Submitted: Yes No Installing Company Name: tfV'kkCecQ OA OA c c �.. Company Street Address: P b iS 0 �' r3 City: n To C) Zip: 0! 2�� Company Phone Number: �� Y -‘e? p & C d Estimated Cost: $ 1/( v Indicate total number of units in the applicable box below M 1 &2 Family Basement L 1st Floor 2nd Floor 3`d Floor Roof Ground" Air Handling /Hydro Units Evaporative & Refrigeration Coolers Heat Pumps Range Floods Vented to Exterior Central Air Conditioners Combustion Air Nentilation Fans t Energy Recovery Ventilators Furnaces- Oil Other: Other: Basic Building Code Commercial Basement S LL vi r 2nd Floor 3rd Floor Roof* 1 0 o V Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units t Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: 5 p Q St 2c I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation Insurance Affidavi equired for all mechanical submissions 42i 6i ature: >1�(;P►wQ.0 Print Name: *rot ((.4v. p, t 4PC. Tvae of License: License #: This Section for Offical Use Only Permit fee: t j. Op , Receipt • • 0 Date Received: 3 ko Received by: 1. Issued By : pproved Date: I Permit or Alteration Number: Revised 8/4/10 AC d_igo /nom /ice -ems- ?) Map #:. Lot #: Unit #: Street#: I street Name: ;greet Unit #: Oepartment:3 «3ldin t): :cuunent Type: (PEEtn. (Pio i Perrr ' TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 -862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 9a4 N Q5 5 0,C h u 0 ?ner of Record: )--1-10 a Sid c 1 j Assessors Map # via. Lot # S) /c Type of Occupancy: (~e,5 '] d t, 0 C New: Renovation:. Replacement: X Plans Submitted: Yes No V Installing Company Name: J Company Street Address: I /7 N J 15 Art City: New '-or) Zip: Q 4 CJ Company Phone Number: 4 1 "1 -- CI t.P 14, .? 3 '?.3 Estimated Cost: $ 59 14 k/ a ti Indicate total number of units in the applicable box below 1 &2 Family Basement 1 L S EC 2nd Floor 3rd Floor Roof Ground* Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: ho t e_r' -- a t' [ I 1 Basic Building Code Commercial Basement o w N 2nd Floor 3rd Floor 1 Roof"' I m o Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: 1 4.4,/J,4,u,. 6 gnature: e U • z ik Print Name: Type of License: License #: Permit fee: 761 00 Issued By : Receipt #: This Section for Offical U e Only Revised 12/31/09 i.2-7 7M, Date Received: y�7 h approved Date: 1 %/zt Received by: Permit Number. ' (0 ' 3 lZ-- J.11xA Map #: Lot #: Unit #: Street II: �s Z4 3 -1- street Name: ,,',355 // T eet Unnt #: 'ernit t #: Department: B cif i)ccutnellt (FerrrO TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: /1 705 Al Owner of Record: Assessors Map # 3' Lot # i C Type of Occupancy: New Renovation: " /Replacement: Plans Submitted: Yes Installing Company Name: 44; // file cA/-A,/ zo-e__ a,L a Company Street Address: ice Gr p' 4t.-City: L Zip: Company Phone Number ?ez - 2 2g . 2 y Estimated Cost: $ ice° Indicate total number of units in the applicable box below 1 &2 Family c a) E m 0 LL o O- u_ N 0 u- 00' o:- is C 2 Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other e)1 eg-v'( '� C1/4,%4/cr." Basic Building Code Commercial Basement] I 1St Floor 2nd Floor 3`d Floor Roofl Ground* Generators Draft inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: e Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's' Noise By -Law: tom'— 1'r I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: griaturgt� Print Name: C3"3 -S6 �s? a3'S- Sa��s ?`� 1 Si Type of License License #: Permit fee: 2 V Receipt #: This Section for Offical Use Only Date Received: ,/,/, I Received by .pc__ Issued By ( `.. , '�' Approved Date: 3 i l7 Permit Number 0 Revised 12/31/09 33('o d_e661 7>tez.,e_ Map #: • Lot #: Unit #: Street#: street Name: Treet Unit #: 'ermit #: 4 1_ 7 ,Z. 7 Z /e -745- Department: di?a Doel,n,ent Type: TOWN OF LEXINGTON E N TERFD .ER APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -2 I 1 Fax: 781- 861 -2780 This Application shall only be used if the work aithorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 4,,,f1/1, :6417 y - 7r/f„,,6 Owner of Record: Assessors Map # y9 Lot # 77 Type of Occupancy: New: Renovation: Replacement: Plans Submitted: Yes Installing Company Name: Goe, > an� � Company Street Address: 57 ,eft City: /(4.,..,A0 Zip: Estimated Cost: $ Indicate total number of units in the applicable box below 1VE 1 & 2 Basement 1 15t Floor _i5 u- -. N o , u Family .. ,co Roof b ° Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces-4/1 a,,,,,,_< .i Generators Other: Basic Building Code Commercial Basement S u- °o u- V o u- V M Roof' o' L 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington): a vlieL o T IAf f3 ��"�i� /70 %2/ bo Print Name: dGC Type of License: License #: This Section for Offical Us On Approved Date: Permit Number: Map #: Lot #: Unit #: Street #: Street Name: Street Unit - Permit #: . 9 zz Department: Document Type: (Plan) (Plot) erm) lidar t-t1)/i-e-eze- /2 AL-d Map #: Lot #: Unit #: Street #i street Name: ,rreet Unit #: _Z g Oepartment: Bui4iing (lc ument Type :. (PIL.g1) (Plc) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: t 04 - 1 AA Mlle c 7 Owner of Record: S 1, In Assessors Map # ` L( Lot # r B Type of Occupancy: 12e M.,A `a,% New: Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: S e.41 P 1 o rh ip ir. y cr, ci Company Street Address: City:Sc cs etth Zip: 0 9'9 6 Company Phone Number: 78(- Z33 7SO 0 Estimated Cost: $ 3so. 00 Indicate total number of units in the applicable box below 1)N1&2 Family Basemenil 0 2"d Floor 3rd Floor Roof Ground* Air Handling Units Draft Inducers Oilfired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces - Oil Generators /,, Other: Basic Building Code Commercial Basement 1st Floor 2"d Floor 3`d Floor Roof* g 0 Generators Draft Inducers Oilfired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of L • •,on: ...WI Signature: Print Name: Mcs u,� su 2e8iy ype of License: License #: This Section for Offical Use Only Permit fee: Receipt #: ?J9' Date Received: W 01010; Received by: Permit Number: / 02 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business / Organization /Individual): S2c&.$ Address: 5 6.7 u..51 -r`3 S? City /State /Zip: 3c,, j ; O 140 6 Phone #: 721- ? 33 -7XOd turnb,�ty ti.�1C arP er Are you an employer? Check the appropriate box: 4. I am a general contractor and I have hired the sub - contractors listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.+ 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] 1. [ am a employer with . employees (full and/or part- time).* 2.0 I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t Type of project (required): 6. 0 New construction 7. 0 Remodeling 8. 0 Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13. Q'Other Gd1 c-li AC C. & I *Any applicant that checks box #1 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 *Contractors 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: 00,1904-0u,... c fL Policy # or Self. ins. Lic. #: G 1-19,k3 Expiration Date: / //eD Job Site Address: ( 72f iYpmt I e S7. City/State /Zip: ey.. -1 ^t 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 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 her rcertifv /�rtnder the "ns an penalties of perjury that the information provided above is true and correct. Signatilre: (c Date: di/VP-0 Phone #: ?fs'(-2 ?3 -73- O0 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5, Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, 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 is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing 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 than 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, §25C(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, §25C(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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(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 Town 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 home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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 Revised 4 -24 -07 Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617- 727 -7749 www.mass.gov /dia e "ay_ 7/ttt" Map #: Lot #: 5 . Unit #: Street#: street Name: 21947 ,;Treet Unit #: '•'rmit #: /0 t,Q/ }Department: 3itilciitr, Diocttment Type: fYitat ictP1p TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in con' with a Building Permit per one thousand valuation or any portion thereof Property Address: y Mc on 14;11 2 Owner of Record: lu 2-c7 r hts\\ kick. Assessors Map # [ (-' Lot # S5g Type of Occupancy: ,tapiccCp New: Renovation: Replacement: '`( Plans Submitted: Yes No Installing Company Name: ray c_ Rect_A-ort3 AC_ Company Street Address: I (d e s %..N City: R j�, \ice Zip: 0 � Company Phone Number: ( -t- - 6q9 r) Estimated Cost: $ ei eee Indicate total number of units in the applicable box a) 0 0 LI- o o oo L LL 0 0 0 0 Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: C Dt. Basic Building Code Commercial Basement o t 2 " Floor Floor Roof" Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: yr s%n � -r r gt#L is lxtsr gc_. / ctr l certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachu tts State Building Code, the International Mechanical Code, and all laws /bylaws/regulati s t n of Lexington PL tot p F °L Sifter Av.e r,tt tirrsrrr W `7t�- rZa2•� C futpn.4.3 pLo„- idtkA- #- /3/2- Print Name: Type of License: License #: Permit fee: I b pp Issued By Revised 12/31/09 This Section for Offical U O y Date Received: /7 l '� Received by 414 Approved Date: cy 1 O -Perm t Number /s(4) Receipt #:.ge l 31, gyt. Map #: _ J Lot #: Unit #: Street#: 'treet Name: /'v,42,,` A52:b r=reet Unjt #: 'ermit #• /o -- 3 3� O Department: f3«iicin ():fcrtment Type: (P! m) (Piot) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building perm' 0- 338766 Property Address: /8 Muni -De, Owner of Record: V F Ye= O' L he Assessors ap # Lot # Type of Occupancy: New: J� enovation: Replacement: Plans Submitted: Yes No Installing C mpany Name: C1%CC r % v 6 Company treet Address: I'� &,v, SionatoJ( City: '3 i //&f/CLL Zip: Ogg/ Company Phone Number:(16 ,)64/0-1.579 Estimated Cost: $ Indicate total number of units in the applicable box below Family Ai[i& Basement 0 e- 2nd Floor 3rd Floor Roof Ground* Air Handling /Hydro Units Evaporative & Refrigeration Coolers Heat Pumps Range Hoods Vented to Exterior Central Air Conditioners 1 Combustion Air Nentilation Fans Energy Recovery Ventilators Furnaces- Oil Other: Other: Basic Building Code C ommercial Basement 1St Floor o i N 3rd Floor o ce Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Btiaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By- w: G Now air s si-Pan I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Co. the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation ranee) fIdaaitrequired for all mechanical submissions Si• . ure: Print Name: Type of License: License #: This Section f Off l U O 1 Permit fee: �� Recei. Issued By ec ion or ica Use n y Date Received: ff /�71/� pproved Date: Revised 8/4/10 AC Received by: L .1 Permit or Alteration Number: v CERTIFICATE OF LIABILITY INSURANCE DATE(MM/D/YYYY) 08/26/2010 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 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 Corso Insurance Agency Inc. 274 Main Street Stoneham MA 02180 7 81- 43 8 - 9567 (.ON TALE John Manetta NAME: PHONE 7816407519 FAX E Ext): (NC, No): -- AIL ADDRESS: PRODUCER CUSTOMER ID #: INSURER(S) AFFORDING COVERAGE NAIC # INSURED SWAT HVAC John Manetta 13 Governor Saltonstall Road Billerica MA 01821 INSURERAAtlantic Casualty TBI INSURERS: 8/26/2011 INSURER C: $500,000 INSURERD: DAMAGE 10 RCN I ti) PREMISES (Ea occurrence) INSURERE: INSURER F: X 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 `NSR W VD POLICY NUMBER EFF (MM/DDY/YYYY) POLICY EXP (MMI D //YYYY) LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY TBI 8/26/2010 8/26/2011 EACH OCCURRENCE $500,000 X DAMAGE 10 RCN I ti) PREMISES (Ea occurrence) $50,000 CLAIMS - MADE X OCCUR MED EXP (Any one person) $5,000 PERSONAL &ADV INJURY $500,000 GENERAL AGGREGATE $ 1, 000 , 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $500,000 POLICY PRO- JECT LOC $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE - - EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER /EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) - If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ )ESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) ✓LIB H 1' f11 L rlVLU GR The Town Of Lexington Building Inspector CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZE REPRESENTATI "© 9988 -2009 ACORD CORPORATION. All rights reserved. kCORD 25 (2009/09) The ACORD name and logo are registered arks `ACORD dteo 74.66d- Map #: Lat #: Unit #: Street#: street Name: ;Treet Unit #: '•'rmit fit-`: 2_ -5 "i/v,ef /e2) Department: Buil ciin i)oc rnent Type: (FE-l) (Plot) (Perm) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: / 491 Owner of Record: Assessors Map # Lot # New: Renovation: Replacement: Type of Occupancy: Plans Submitted: Yes Installing Company Nam ` . Construction 01%ecialtjes P.O. Box 53 Company Street Address. Stoneharrt 0718 City: Company Phone Number: — G 6 c - I C� Zip: Estimated Cost: $ 4 Z77 e /f Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &' 2 Family Basement . I °o N 2nd Floor I o 'O Roof L Air Handling Units Draft Inducers ON fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil M P O O c-#M Generators Other: Basic Building Code Commercial Basement I 8 - N 2nd Floor 3rd Floor Roof 0 0 Generators Draft Inducers ON fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: M P O O c-#M Describe Project: `Note: If any equipment is being placed outside oft rint of the building, indi'.te set•acks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws/regulations of the Town of Lexington: Signatu4e R,4 /k F-( Ai Print Name: ("--114'fra-4-15- Type of License: C55-3g- - 7 -2 License #: Permit fee: 2-7 Issued By : Revised 12/31/09 Receipt #: This Section for Offical Use Only 77J Date Received: 8/9 j/0 Received by: Permit Number: r.amc: 1.o-n !ion c( )vcN 1: fit: ;I; ..(>4.7.)l'a.ahl,nRion sS'Ire 417,9,1npyihisitron-Ins wanes- ,ti",';;!..rt.11 ConstructioriUgRAV ilx1131.Y P.O. Box 53 ' • .; 11 ir■ • A .:t hoolcowncr pc, forrainc &U yeotk'mysclf. • I A f:1 to!: proptictor.and VC .no one ‘slorkine in any capacity, am an employer prvviiiinc I■ott;crs' .ortiperaztion for my c,mploycc.: wotkinc on t!'.is rumc: Phone Phone 0 44' . !r3n:c Company: Policy: fl ant :ol: proprictor, ccnc•al contractor, Of htrICOWIICf (circle one) and love hired th: Contra.:tcrt t.dow who havc the workcrs comp4ruatIon policy: Company narnc: Phone ,) addrc:s: OCy: Statc: Cotnpany: Policy: _ namt: Construction Specialties --P:0; Box 53 Phone 70'(-665---LeLt (,..—„),3.Ltrc4:: Stoneham. MA 02180 city _ State: ,06/ .:!-.1:,..7c Cotnpany: NA-7-1_ UN] 0,-) elAP--folicy: slt l._ .,..,tacli ac:.1tiortal ects if ncccssary. .'S C-0 , : to sc.Cure covcrace it rcquired undcr Section 25A of MCI. .152 Cafl !cad to the implementation a c!i:....i.r.al p:rultics of a fine up to $1,500.00 Lnd / or one ycari' impri:onmcnt as ‘vc11 as civil p:n..dtits in t:..,-. form I "STOP \YORK ORDER" .1nd a floc of 5100.00 a daY again mc. .1 undcrsta.nd that a copy cf 1.1 721 .:. .., A i ...;,. 1.:1,,:tnc.nt nay In forwanicd to the Office of Inycstication of tilt D[A for eovcra c v rifc-at' , . ...i., I: e re !,). CU rib, 'a..1, the paint and petraltie I .... -.ii..:,..,:urc C:( A pplica (ion; - I'::::; r..1:n7.• • ______ T • -.• (:!) not writc 1,!:it - t In completed by city Cr to%vn cfr:•:ia! _ Pcrinit 1);pt: d-4e4 741,t- Map #: Lot #: Unit #: Street #: Street Name: ;meet Unit#: rnlit 63 157`E 3 4 fre coa7— Department: Building Docl ment Type: I Perm TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 - 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 41JIC,- 67,4- Owner of Record: A� n� Assessors Map # 3 Lot # / /5,q 3 / Type of Occupancy: ,r,doi New: Renovation: Replacement: x Plans Submitted: Yes No X Installing Company Name: C p" --ro k C (, c #eouhrlg Company Street Address: 9 Al, Nlap2 S - City: GUI Zip: 6 /id) Company Phone Number: —7 k I — / — Li ci Estimated Cost: $ c Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement 1St Floor 2nd Floor 3rd Floor Roof /° V Air Handling Units x Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners ,x Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: Basic Building Code Commercial Basement o u_ T 2nd Floor 3rd Floor Roof* Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: Pc21( .re ex r , <} -(;�Qa, Ps 1c`_ % e.42, j I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massach e ate Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of L iggt ,s ti, /14 0.,/ Type of License: This Section for Offical Use Issued By : Date Received: 6 Revised 12/31/09 rc/3 7,4-7 License #: ! Received by; oved Date: 44�/ 4Permit Numb Workers Compensation Applicant inforniatiow The GlitallealWealth ofMassachusetts Department qf Industrial Accidents Offiee:' 600 Yllaskington Strectt Bo stems.. MA (111,1 Insurance Affidavit ersiContr a eth Ts/Elect ri clans/Pit! mixt Mp# Lot # _ Address Per ntit _ ,s• Please Print Ltgitiv A you an employer? Check the appropriate box: .152j I am a eniployer with t5;,— [ I I am a general contractor Type of project (required): t -,Y employees (full and/or part-time).' 2. Li I am a sole proprietor or partnei- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers' comp. insurance.$ 5. j We are a corporation and its officers have exercised their right of exemption per MGL c. 152 §1(4), and we have no employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 2Conmeters that check this box must att.ched an additional sheet showing the name of the sub-contractors and stale whether or not those entities have cmployees. If the sub-contractors have employees, they must provide their workers' comp. policy number, am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site foforni cation, inSUTaI]Ce Company Natne:_, Pdicy Li, 6, U New construction 7. 1:1 Remodeling 8. J Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13,0 Other A)/ Act:. 4-lc or? Expiratioh Date: Job Site Acre: 41, py tvier City/Siatc/Zip: Lex 07,2,4",r, much a copy of the workeW compensation policy declaration pa...gc, (showing the policy numbet and expiration date), rjit c. sccute covet nge ec:uired under Seclion 25A of 1461, c f52 c'Er, F lo Coo imposiliol to 1 500.00 andlo oric; impyisournoni, as well t,s civil pe,nalties in the fc m of a STOP WORX ORDER and fine of np to ,2.50,00 a day piist tho vidator. Br advisd that r cepv of this statcnK;nt *nu 1c forwalde6 to the Office of „Inv estiga0ons ot,.thopi_Afor wveiage verifica:Lion._ d hereby eertifii under the pains and periattes a/perjury that the information provided chore ts iu e d lTea, gflje Phone #: Date: Officio! use only, Do not write in this orea, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2, Building Department 3. City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person:____ Plaint _ _ In :Orination„ and etion F ,, en.417,10..yer6:; to, provide N.vc,r1...ti:s' compensa.ii.(Oi . for their slo.turu„. ,..-..yiutrzot e.x.i.,;:r...e.L•F:. Oa c):al • An emplayeri r partile,rship, otb,o, legal adity, or any two G. mord. of vif foregaing.engagie:d. in a it teiiFc, ond including the legal representatives of a dect.ued employe,r, Co . the Itecivey irat ee individual, partnership. o',..udir.itiOn Co othur legal entity, erroloying employeef:, itawaYer tin owutd. dwalling holve,hvini,: not the. ',.--,partment::. and vim It„sidas thelein.„ cg: OCC:Op.oth: ul the arstelling. no-ore of who m no on.ainterianuc, constracdoi., 1.,eparif woik. sudii buildhig atoomd.tthard theterst slim:: reit Isecatuto tyf suds, te, e-s C/, ft,,,F,tij a km, y renewal et a license or pt i wit to operate a husinet s oa Os, eonstl-oet huildirsgs in tba evrantoavi'ealth for My applicant who has not produced acceptable evidence of cempliance with the iMtrl ance coverage required." Additionally, M.GL chapter 152, §25C(7) stales "Neither the commonwealth TiOr 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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(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-ine.trando license numbor on -the appwilliard City or Town Officials Please be sln.e. that the affidavit is complete: card printed legibly. The Department has provided a spade at the bottom of the affidavit for you to fill out int the, event the Offics.: of Initeptidarions has to contact yorr regarding the applicant Par bs, r-ore Co fill in the utrastititic(timst "in', r which v'ill ha dhoti!. Ct a T,,le-g.-,13c.c'. nor'"-' la addition At applicarn iffahiple applicaickinS 10 aDy an :,),•.`,44, heed only submn Co ns, affidavii indicating cup cid policy ilifdrimlion nsac kstiry) -416.u:rider ,Yob Site J6,..d.6:SCEE," the applicant should V.71-itt, "ci locTlions to-wil), A copy of the ffis.l.tovii that ha m been officially stardpM or Yililked by the city et town. irity be po: el idea to ri aPP:Ileani trttt FOCI: tTa a all fSikikWit is" en fib' fb re:We pennitF: or licenses, new affidavit midst in filled 001 year, A'OSlO v home, owner- or ('P'S an is obtaining F tic ems m WISA 130, data e ta airy business Co eskihmeticial ventars (Lc,. tf sag inn Co pc,IMP, k-toR'.-E' Or.%) 'inn' - NOT re,huites1 to' complete Ibis affidavit, TItti Office of Invektigationtt would lire, le that& you M ttolvance for our coopmtiou and should vets hive any quest:MI; ple,tcse 4io net hesitate, tu give' t)s a WI, The Department's address, telephone and fa* nmnbey: Cornattotiwatth of Mas=husUts Department of incilmtrial Aceidelits Office of Investigations 600 Washington Street Boston, MA 02111 Revised 11-22-06 Tel. ' 617-7274900 ext 406 or 1-877-MASS Fax # 617-727-7749 www,rnass,govidia