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24C-014 (6) COMMONWEALTH OF MASSACHU DIVISION OF PROFESSIONAL LICENSURE - BOARD OF p rSSACH T I S • HEFT METAL WORKER DICENSE A A ""MASTER- UNRESTRI LICENSE t E - „/' +tam iH 0 � M . u ISSUES THE ABOV "LICENSE A 4 ogee 4d NUMBER NONE ARtN .S MBE 1 N; !It $� • kk _ �' 15 SEX M.; is ii 140 WES t' ST �f � • oe • ti s ±tt' Ti HA: 1�>�a -9�Sa 0 3 64:8 e 140 0 WEST ST W S 1 /28/1 I HATFIELD, MA 01088.9500 f 5 W 15.10.1010 Roll 07.75.2009 LICENSE NO EXPIRATION DATE SERIAL NO. 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 anthonty." 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 T.T.P 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 Commo of Massachusetts Department of Industrial Accidents Office of Investigations - - - - 600 --Was iington Str-eet.____ - Boston, MA 02111 Tel, # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE Revised 4-24-07 Fax # 617- 727 -7749 www.mass.gov /dia The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations N ,, 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) Q i e 1 iei Address: ' (7 we 5-7- // 01084 City /State /Zip: We-51" t f l , fr Phone #: ( 1 7 3 Are you an employer? Check the appropriate box: Type of project (required): 1. E 1 am a employer with 4. [] I am a general contractor and I employees (full and/or part- time).* have hired the sub- contractors 6 ❑New construction -n dam a sole-proprietor- or partner- listed on the attached sheet. - 7. [ Remodeling ship and have no employees These sub- contractors have 8. [ De olition working for me in any aci employees and have workers' g Y ca P t3' .__ 9. Building addition Q ekchao(k [No workers' comp. insurance comp. insurance 5. We are a co oration and its 510.0 Electrical repairs or additions required.] ❑ �.. 3. [ I am a homeowner doing all work officers have exercised their 11. [Plumbing repairs or additions myself. [No workers' comp: right of exemption per MGL 12:0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] `Any applicant that checks box #1 must also fill out the section below showing their woricers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. / — Insurance Company Name: 7/7" G i,.-/t j 1/ ct -4t(..a- ( S C C . Policy # or Self -ins. Lic. #: lit/ C7 j Q O D Expiration Date: 3 — —l3 _�. Job Site Address: # )Sy O/s?5 _fl City /State /Zip: Af R Gt oG - . 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 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct — - Signature: Date: Phone #: -._ . _.._ Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # =- Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: INSURANCE COVlWE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes E No ❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy V Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee dnPS not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waivPsthis requirement. Check One Only Owner L� Agent ❑ Signature of Owner or Owner's Agent By checking this boxD, I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Prngresc IncpPrtinnC nate Comments Final IncpPrtiOn Bate r orriments Type of License: By ❑ Master Title ❑ Master - Restricted City/Town ❑Joumeyperson Signature of Licensee Permit # ❑Journeyperson- Restricted License Number: Fee$ ❑ Check at www macc gnv/ripl Z ---- //7 7/' Inspector Signature of Permit Approval Commonwealth of Massachusetts City Of Northampton W 2 3 2012 DEPT. OF BUILDING INSPECTIO Date: .9'p73� Sheet Metal Permit Permit # NORTH AMPTON, MAGIC Estimated Job Cost: $ 4 9 / 0 - 0O.0 0 Permit Fee: $ 0 Plans Submitted: YES NO Plans Reviewed: YES NO Business License # S3 3 Applicant License # Business Information: Property Owner / Job Location Information: Name: 44"//19141\--54e-i7vie k ( Name: -row, e P& /c rdo Street: / / yO r,.. -S f . S�f/� e � Street: 2 Sy City /Town: CP5 7 ` l >° l /0010 8' City/Town: 4 r ri -/h-p _a 0/D 6 Telephone: y/ 3 ay70 S Telephone: Cei7 ( l i 3 — ya7 — /1-(/‘ Photo I.D. required / Copy of Photo I.D. attached: YES v NO Staff Initial J -1 / M- 1- unrestricted license J -2 / M- 2- restricted to dwellings stories or less and commercial up to 10,000 sq. ft. / 2- stories or less Residential: 1 -2 family Multi - family Condo / Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. Ever 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: Renovation: ✓yJt r� HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney / Vents Air Balancing Provide detailed description of work to be done: P ro vt• - F (C) © ke 27 Fees 27 ; � ro�,•�- , Fees with Building Permit: $25.00 Residential, $50.00 Commercial. Fees for jobs without a Building Permit $6.00 per $1000 Minimum fees for jobs without Building Permit $50.00 Residential, $100.00 Commercial File # SM- 2012 -0027 APPLICANT /CONTACT PERSON AARON MORIN ADDRESS /PHONE 140 WEST ST (413) 247 -0550 0 PROPERTY LOCATION 254 PROSPECT ST MAP 24C PARCEL 014 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out a5 Fee Paid J Typeof Construction: DUCT WORK FOR ADDITION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 533 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I O ION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER : § Intermediate Project : Site Plan AND /OR Special Permit with Site Plan Major Project: Site Plan AND /OR Special Permit with Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee t m lm Street Commission Permit DPW Storm Water Management Signature of B ilding Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact the Office of Planning & Development for more information. 254 PROSPECT ST SM- 2012 -0027 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON IGIS #: 3696 Map: 24C ; IBlock: j014 r��Ci� Lot: 001 SHEETMETAL PERMIT " Permit: ,ss =- ,5 ;SHEETMETAL EM1TENPR fir _ - _ -- - -- Category: Zoning Permit Permit # sM- 2012 - 0027 PERMISSION IS HEREBY GRANTED TO: Project # JS -2012- 000254 'Est. Cost: $2,000.00 Contractor: License: Expires: F g Flee Char ed:'$25.00 AARON MORIN Sheetmetal - 533 10/28/2013 � Balance Due: $.00 Owner: PAPPALARDO THOMAS J & SARAH E SMITH # of Fixtures: Applicant: AARON MORIN DigSafe # AT: 254 PROSPECT ST UseGroup ConstC lass ISSUED ON: 28- Mar -2012 AMENDED ON: EXPIRES ON: TO PERFORM THE FOLLOWING WORK: DUCT WORK FOR ADDITION THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fixtures: Floor: Type: # of Fixtures Floor: Type: # of Fixtures Fee Type: Receipt No: Date Paid: Check No: Amount: Sheetmetal REC- 2012 - 004768 27- Mar -12 1302 $25.00 212 Main Street, Phone:(413) 587 -1240, Fax:(413) 587 -1272, Email :lhasbrouck @northamptonma.gov GeoTMS® 2012 Des Lauriers Municipal Solutions, Inc.