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32A-172 (5) 07/31/12 11:03 AM Page 3 I I I a yY V> : �' {fl57UA6; ' ' �,.. �, � , 0:•'• * fifa'li }i M p' ''.,c. 1 S M' f' p m, 1s 1�1 PA �d ' Yr" ' p f . « t', :: ' Ilf. .: .., '.,, - ........"4: '..: .',:'....,.,..;: .,• ...,•,.... ...1, .. w � ¢ r Ej r R i , p �A ' 1. `'Y, F' . at `° '''.::''''°: ''''. Ii, �� i : 4 moat 3 96 • • i r ` • • C I i • U� ti* J vpEG gLtt %)''' Feld. Than DEach A AI Fern n1iis COMMONWEALTH OF MASSACHUSETTS - '1V3SIOH OF PPO FESSJONAL IJCENSURE- BOARD OF BOARD - SHEET METAL WORKERS SM .AS A BUSINESS ISSUES THE ABOVE LICENSE TO: TYPE PAUL J` CHEVALIER I ACTION- AIR INC -B • ••1`11 • INDUSTRIAL LANE • • .. • . AGAWAM • MA 01001 -0041V 12425 375 05/12/13 . 12425 • ' = LICENSEiJO - EXPIR -DATE • • - SEREALNO. Along A'I Pe'fof3`On5 CD N jr v i t:= g r, _: �� ! `, ,' I S s� ....a : :-1 'xi IR . ,n - ,��„ .. 6-! OC..1.17.I I1 My�7 +1 _ 1a�'' /tM 9.4°116411--- i Fo1dAL � 'r ASS f„ ', E LjHO ES[, s.D�0c Y � r ' , ' SR E .r Uw 510 t S IRI K UNR � � ..:'-''?---'''1.''''' yam t SE AR 1 n } SM jV Al ,, .. z - 9a4 j : " roc ExF' ■auTiori a r ao =i _∎GENGE,� oFMPetTash 5t Frin� ACORD CERTIFICATE OF LIABILITY INSURANCE DATE 0501/20 TM PRODUCER Phone: (413) 781 Fax: 413 - 731 - 9539 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INSURANCE CENTER OF NEW ENGLAND INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1070 SUFFIELD STREET HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P 0 BOX 1230 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. AGAWAM MA 01001 INSURERS AFFORDING COVERAGE NAIC # INSURED , INSURER A: Central Insurance Company 20230 ACTION AIR INC INSURER B: Commerce Insurance Company 34754 P.O. BOX 636 INSURER C: FEEDING HILLS MA 01030 INSURER D: INSURER E: 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 AUIYL 'TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE 1 POLICY EXPIRATION LIMITS LTR INSRD DATE IMMIODIYYI 1 DATE (MMIDDMr) GENERAL LIABILITY CLP7978942 j 04/30/12 1 04/30/13 EACH OCCURRENCE $ 1,000,000 ■ X i COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 300,000 i PREMISES (Ea commerce) CLAIMS MADE X OCCUR I I I MED EXP (My one person) $ 5,000 A PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS- COMP /OP AGG $ 2,000,000 PRO - POLICY ,IECT LOC ! AUTOMOBILE LIABILITY YM3030 04/30/12 04/30/13 COMBINED SINGLE LIMIT 1,000,000 I ANY AUTO (Ea accident) $ • ALL OWNED AUTOS BODILY INJURY • X SCHEDULED AUTOS (Per person) $ B X I HIRED AUTOS j BODILY INJURY $ X 1 NON -OWNED AUTOS (Per accident) I PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG S EXCESS / UMBRELLA LIABILITY CXS7978943 04/30/12 04/30/13 EACH OCCURRENCE $ 2,000,000 ' X OCCUR CLAIMS MADE AGGREGATE $ 2,000,000 A $ DEDUCTIBLE $ RETENTION $ 0 $ WORKERS COMPENSATION AND WC797894416 04/30/12 04/30/13 X ORY TS 0T HER EMPLOYERS' LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? : E I DISEASE - EMPLOYEE $ 500,000 II yes. deec,lbe (rode, SPECIAL PROVISIONS below E L DISEASE - POLICY LIMIT $ 500,000 OTHER: DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS TO SHOW EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE FOR VERIFICATION OF INSURANCE PURPOSES ONLY TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, IT AGENTS OR REPRESENTATIVES AUTHORIZED REPRESENTATIVE . ' 414114 1 1144/4.— i • Attention: p . Gallagher ACORD 25 (2001/08) Certificate # 62630 © ACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations 600 Washington Street Boston, Mass. 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information / Please Print Legibly Name (Business/Organization/Individual) : �° I/O 4 / �� /' f / 1 Address: P - 0 . (0 3( City /State /Zip: +ego r'C N I I Phone #: ( J/ .) - 2S' �'/ -9 6 - Are you an employer? Check the appropriate box: Type of project (required): 1.. - I am an employer with ) 4. ❑ I am a general contractor and I 6. 0 New construction employees (full and/or patftime).• have hired the sub - contractors emodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. $ 9. ❑Building addition required] 5. ❑ We are a corporation and its 10. 0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑Plumbing repairs or additions myself [No workers' comp. right of exemption perm MGL insurance required] t c. 152, § 1(4), and we have no 12. 0 Roof repairs employees. [no workers' 13.0 Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contactors that check this box must attach an additional sheet showing the name of the sub- contractors and slate 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: Ci y) `tf / , J � 1?d /7 e ( 642pao Policy # or Self -ins. Lic, #: we 7 g - ?(:),(7/40, Expiration Date: Job Site Address:/f 13th d t: Jf City/State /Zip: 7)60/10n Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration (date). Failure to secure coverage as required under Section 25a of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage e ' ication. I do herby ce i nder the airs n enalties of jury that the information p ovided above is true and correct. Signature: 116 ' r Date: '7 /Dd Print Name: Rile (,) Phone e #: V13 - 7 �SS Official use only Do not write in this area to be completed by city or town official City or Town: Permit/license #: Issuing Authority (circle one): 1.Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact person: Phone #: INSURANCE COVERAGE: 1 have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes ❑ No ❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am "' am "` aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑, I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Cods and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Proeress Inspections Date Comments Final Inspection Date Comments Type of License By 0 Master / IIIP\ / • Title ❑ Master - Restricted City/Town ❑Journeyperson Signature of Licensee Permit* ❑Journeyperson - Restricted License Number. 7/ / Fee$ ❑ Check at www.mass.bovldpl Inspector Signature of Permit Approval Sheet Metal Permit Date: 7J i 0 Jj a- Permit # Estimated Job Cost: $ 4 i , z) S, 0 r , t .F - Permit Fee: $ 5 .LL:::: Plans Submitted: YES NO 1 1 Plans Reviewed: YES NO -\--- ' JUL 1 2 2012 Business License # Applicant License # L Business Information: °` r r Property Owner / Job Location Information: 5i.f/y;a 0 oitetca, -- r2c,s i � i. Name: � i r I e Jna Name: C t i l e e .J a ile Street: ?ID . t`2 b 36 _, treet: /1 --L.5 8eid City/Town: FT 14; //S fir O3 Cit f n pJ I o nl /e ✓l 4114.- - Telephone: t/ 0 _ 2 9 q6,63--- Telephone: Photo I.D. required / Copy of Photo I.D. attached: YES )( NO --------'-D Staff Initial J -1 M- 1- unrestricted license J -2 / M -2- restricted to dwellings 3- stories or less and commercial up to 10,000 sq. ft. / 2- stories or less Residential: 1 -2 family Multi - family Condo / Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: k Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney / Vents Air Balancing Provide detailed description of work to be done: (-I e4-14 ,i) - Stu/4- o l She ( 5 0 0-- :S f J tv1 m itoi? S 1,4 St 4-) aoi dyd5 - j G,l' ,/, Iif PJCttI/i sciriai. 15 (S)de yf e 0m /s ( -) arye h -- . ......, File # SM- 2013 -0004 APPLICANT /CONTACT PERSON ACTION AIR ADDRESS/PHONE P 0 BOX 636 (413) 789 -9305 PROPERTY LOCATION 15 BRIDGE ST MAP 32A PARCEL 172 001 ZONE CB(103)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out (5.-- /a Fee Paid 45D Typeof Construction:_DUCTWORK - RANGE HOODS,EXHASUT FANS, SPLIT SYS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 7110 3 sets of Plans / Plot Plan THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I RMATION 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 • /`,. . "fi Co • .':•.ion Permit DPW Storm Water Management _,'___ ....1./ 7-13/.-- Signature of Building Officia 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. 11 -15 BRIDG ST SM- 2013 -0004 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON GIS #: 10007 o Map: _.... _ - Block: 17A , 01444117 001 3 SHEETMETAL PERMIT Permit: SHEET.:: , AL _ -{ T£RCENiENpBYi Category: SI IEEI M I a AL Permit # SM 2tl l ' - PERMISSION IS HEREBY GRANTED TO: Project # JS 201? ' 171 Contractor: License: Est. Cost: � I __�,o�� Expires: Fee Charged: �i).00 ACTION AIR Sheetmetal - 375 05/12/2013 Balance Due: $.00 Owner: WOICEKOSKI SYLVIA M TRUSTEE 1# of Fixtures: Applicant: ACTION AIR - 1 DigSafe # ' AT: 11 -15 BRIDGE ST UseGroup ConstClass ISSUED : 3 012 AMENDED ON: EXPIRES ON: TO PER HE FOLLOWING WORK: DUCTWOE' - 1' I IOODS,EXHAOXFANS, SPLIT SYS THIS PEI\ ,T :. 3E REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF I' R L; AND REGULATIONS. Signature: Fixtures: Floor: # of Fixtures Floor: Type: # of Fixtures Fee Type: Receipt No: Date Paid: Check No: Amount: Sheetmeta REC- 2013- 000147 13- Jul -12 5010 $50.00 : Vain Street, Phone:(413) 587 -1240, Fax:(413) 587 -1272, Email :lhasbrouck ®northamptonma.gov GeoTMS® 2012 lies inicipal Solutions, Inc.