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31A-088 (4) The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 wM www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le0bly Name(Business/Organization individual): Aaron Morin Sheet Metal Address: 140 West Street City/State/Zip: West Hatfield, MA 01040 Phone#: 413-427-1416 cell Are you an employer'Check the appropriate box: Type of project(required): 1.❑1 am a employer with employees(full and/or pan-time).* 7. ❑New construction 2.a I am a sole proprietor or partnership and have no employees working for me in & F1 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.II am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4❑1 am a homeowner and will be hiring contractors to conduct all work on my property_ I will ensure that all contractors either have workers'compensation insurance or arc sole 1 1.Q Electrical repairs or additions proprietors with no employees. 12-E]Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.• 14.®Other 6.❑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 41 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. 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: National Grange Mutual Insurance Policy#or Self-ins.Lic.#: WCTI O90D Expiration Date-3-22-2016 Job Site Address: f7 tU'dtv,-s City/State/Zip: (i•� CSI U Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration ate). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi der the pal nd penalties of perjury that the information provided above is true and correct Signature:, Date: Phone#: 413-427-1416 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#- INSURANCE COVERAGE. I have a current liability[insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes No❑ If you have checked Yes, indicate the ty of coverage by checking the appropriate box below: A liability insurance policy Other type of indemnity El Bond ❑ YP Y OWNER'S INSURANCE WAIVER:I am aware that the licensee does nnf haves the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waive this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box[],I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and Installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO 77-��,,,,����,, PYngrpgc Irn Cnerfionc JJI t-- Comments Final TnSperfinn Date CnmmPntc ;Type of se: [By Master le ❑Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: Fee$ ❑ Check at Urmpif mac- gavidpi Inspector Signature of Permit Approval Commonwealth of Massachusetts City Of Northampton Date: _�Z—( Sheet Metal Permit permit# l Estimated Job Cost: Permit Fee: $ �� o�� Plans Submitted: YES NO ✓ Plans Reviewed: YES NO Business License# Applicant License# Business ormation:n j Property Owner//Job Location Information: Name: S� ti( Name: �l e4 Street: 1 Llo 1,,jes-f 5k&e-r- Street: 17 Vefl"IoA City/Town:(� I � 1 1 0 ` �� City/Town: /� 7 a✓ Telephone: Ll C �a7' q Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES NO Staff Initial J-1 /M-1- estricted 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. I/ over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents—Z Air Balancing Provide detailed description of work to be done: GL �r f- 5"�(V IA 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-2016-0028 APPLICANT/CONTACT PERSON AARON MORIN ADDRESS/PHONE 140 WEST ST (413)247-0550 Q PROPERTY LOCATION 17 VERNON ST MAP 31A PARCEL 088 001 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 yr Fee Paid Typeof Construction: INSTALL STOVE PIPE FOR WOODSTOVE 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 INF 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 Permit from El treet Commission Permit DPW Storm Water Management Si u r e wilding 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. 17 VERNON ST SM-2016-0028 COMMONWEALTH OF MASSACHUSETTS _ CITY OF NORTHAMPTON GIS#.__ 15699 Map: �31A B'Oek -- °gg -- - SHEETMETAL PERMIT Lot: 1001 �Fermit: SHEETMETAL 'l�f Category. SHEETMETAL { 1 Permit-4 SM-2o16-oo2s- PERMISSION IS HEREBY GRANTED TO: Project# JS-2015-001917 Est. Cost: 800.00 y Contractor: License: Expires: $ Fee Charged1$25 00 AARON MORIN Sheetmetal-533 10/28/2017 jBalance Due:$.00 Owner: ALPER GLEN C#—of Fixtures ]Applicant: AARON MORIN DigSafe# - SAT: 17 VERNON ST !UseGroup ConstClass ISSUED ON. 28-Dec-2015 AMENDED ON. EXPIRES ON. TO PERFORM THE FOLLOWING WORK: INSTALL STOVE PIPE FOR WOODSTOVE THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Sheetmetal REC-2016-003018 28-Dec-15 2461 $25.00 212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck@northamptonma.gov GeoTMS 2015 Des Lauriers Municipal Solutions,Inc.