23A-005 (9) 36 MEADOW ST SM-2018-0049
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
CriIS#: 2746__.
lap: 23A
Bot �1 SHEETMETAL PERMIT
__ _.
Pet7nik ,SHEETMETAL
Catag�AL
Permit# SM-2018-0049 � PERMISSION IS HEREBY GRANTED TO:
Project# S201&001898
Est Cost $16,206.00 Contractor: License: Expires:
Fee Cl arged $25.00 ACTION AIR Sheetmetal-7110 0628/2018
Br=reup
lance Due.$.00 Owner: CARLSON ALEXANDRA
#0'
fFixnues: Applicant: ACTION AIR
afe AT; 36 MEADOW ST
'FoavtClass -__
ISSUED ON; 21-May-2018 AMENDED ON: EXPIRES ON:
TO PERFORM THE FOLLOWING WORK:
FURNISH&INSTALL AIR HANDLER,CONDENSING UNIT,DUCTWORK,RDGS
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:
Sheetmeml REG2018-005891 I8-M4-18 4781 S25 00
212 Main Street.Phone:(413)587-1240,Fax:(413)587-1272,Email:Ihasbrouck,*nomhamplonma.gov
GeoTMS*2018 Des Laurien Municipal Solutions,Inc.
File d SM-2018-0049
APPLICANT/CONTACT PERSON ACTION AIR
ADDRESS/PHONE P O BOX 636 (413)789-9305
PROPERTY LOCATION 36 MEADOW ST
MAP 23A PARCEL 005 001 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
Fee Paid
TvoeofConstruction, FURNISH&INSTALL AIR HANDLER,CONDENSING UNIT DUCTWORK RDGS
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9BMATION 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:
_Cub 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
Per
mit
from EIm Stree[Commission Permit DPW Storm Water Management
41,,e.. Buld' toicgm ateance 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.Concoct the Office of
Planning&Development for more information.
d �heet Metal Permitcy 4-6
Date: Permit# 5rn - i9- Y9
Ck) \/
0 Est' d Job Cost S ��G'a(J�-.� Permit Fee: $ d5-.lJ—�
W m uo
> RPI 6` miffed: YES NO _ Plans Reviewed: YES_ NO
W m io
U Busi License# Applicant License#
c d
LU =Bus �s Information: Property
(Owner/Job Location/Iynformation
Name AnY C Name: \�.1,yhgt,U. \ �1'..✓ I SUV�I.
Street. 1 Street: 2)b I(t'npadO,-) SA 1�5�1
City/Town '4A-Qy Rt�G-, ►� �w City/Town: Y'-lplMV\�Qr^� \
Telephone:. -Y�� -�'dA {- �3�5 Telephone.
Photo I.D. required/Copy of Photo I.D. attached: YES NO _
Gua bma
J•1 M-1-unrestricted-- liceu�-
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.l—t 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 _ Air Balancing
Provide detailed description of work to be done
"Fun/dsk ai&d irl�-txJCk' air- ka_AdbL
INSURANCE COVERAGE: ,,��^/
1 have a current liabilityinsurance policy or Its equivalent which meets the requirements of M.G.L. Ch. 112 Y.?. , -❑
It you have checked Yes,Indic�atIssJ(f�a type of coverage by checking the appropriate boa below: �[�[C
A liability insurance policy,{o Other type of indemnity ❑ Band ❑
OWNER'S INSURANCE WAIVER:I 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 wolves this requirement.
Check One Only
Ownek Agent ❑
Signature of Owner or Owner's Agent
By chocking this Whereby unify that all of Inti details and information I nava submitted(or anionic)regarding this application are true and
accurate to the best Y knowledge and that as afuet metal work and installations padermed under the permit Issued for this application will be
in compliance with all pertinent provision of the Masnehuseb Building Code and Chapter 112 of Ina Consist Laws.
Duct Inspection requlred prior to Insulation installation:YES_NO
Proeress Inspections
Date Comments
Final Inspection
Date Comments
Type of License:
By aster
Title 0 MasterResltlded
ClryRown
❑Journeyperson Signature of Licensee
Permit a
❑JourneypersonResinctea License Number. —7«(/
Fee$
Check at www.mass.00vidol
Inspector Signature of Permit Approval
The Commonwealth ofMassaehusens
Department of Industrial Accidents
. _ Office oflni,emtigations
- 600 0ashington Street
Boston,MA 112111
wwH'.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lei 1
Name(Businm/OrganiizzaafioML'�/)
ndividtW)::-a __ ✓1
Address:_ Y0 &K (OJl, /y, (� p z -
City/State/Zip: I 1�(4N�J 7 -
A
on
ao employer?Check th propriale box: Type of project(required):
1I am
2.
employer with�_ 4. ❑ I am a general contractor and I
111111 ______ + have hired the sub-contractors G ❑New construction
employees(full aod/m part-time). p.��
2.❑ [am a sole pmprictor or partner- listed on the attached sheet. 7. 2CIJremodeling
ship and have no employees Thee orb-contractors have g. ❑Demolition
working for me in my capacity. employees and have workers'
[No workers'comp.insurance comp. insu mac'. 9. Building addition
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.E3m I aa homeownerofficers have exercised their doing all work 1].❑Plumbing repairs or additions
myself.[No workers' comp. right of exemption per MGL 12 Roof r
insurance required.]t a 152, §I(4),and we have no ❑ errs
employees. [No workers' 13.❑Other
comp. insurance required.]
•Any appheont Jut ehectr box Pl event also fill on,the seetten blow showing their workerseempemarou policy Worndnno .
r Honu ..who submit this affidavit indicating they art doing all work and then hire ounide contract..shun wbmit a new d5devit indintin&such.
lConmeton that chonJ this bog most amcbed en additional Shen showing the come ofth,mb-,vo ncton and stale ehrnh ,or not these endue.brave'
marloyeea. lion wb-ecemeton brave cen,Ioyees,thry,must provide their workers comp.polity number.
1 am an employer that is providing workers'compensation Insurancefemployee& Below is the policy and job site
informarioa
lasurmcc Company Name: OII,^, n
l,,7 eVrt_`{-L,� nSLl4($IL.C°' 11�n��� f/tc.YiN
p
Policy#or Self4ris. Lic. #::y XWO S(o ( 0,53c) 1 Expiration Date:_
Job Sita Address: 3vi fyuc L u St, City/State/Zip: �l[N`2f�t CPQ, M1q olblo
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 w S 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 a coverage verification.
Ido hereby a under eh p and (ties of perjury that the information provided abotvee is true and correct
Sianetom r ( �y (y 7 Date' S�1 7�1
Phone# `f — I
Official use only. Do not write in this arta, m be completed by city or town official
City or Toon: Permit/Lianse#
liming Authority(cirek one):
1.Board of Health 2.Badding Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
CERTIFICATE OF LIABILITY INSURANCE DATE411DY
Aonvo+e 2018
CORO
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 pollcy(lee)must hew ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IB WAIVED,subject to the arms end conditions or the policy,certain policies may require an endorsement. A statement on
this caninome does not confer rl ha to the ceNRc m,holder In lieu of such entlonament(s).
P0.000CER I NXAp Laura Me"De
Berksblre Insurance Group,Inc A E (413)447-1370 Ip (413)499-0918
43 East St ADDRE Imlasedaba luthimin¢uransegroup.com
PO Box 4869 INSUREUSAFFORDING COVERAGE NAICE
Pittsfield MA 01202 INSURERA: Ohio Security Insurance Com"Ry 24082
,usu... INSURER a' American Fire 6 Casualty Co 24006
Action Air,Inc INSURER C: The Ohl.Casualty Ins Co 24074
PO BOM 836 INSURER D;
INSURER E:
Fees.,Hill¢ MA 010M INSURER F:
COVERAGES CERTIFICATE NUMBER: C1.1841953194 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. NOTWHHSTANDING 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.
LTR TYPEOFINSOMNCE POLICY NUMBER MMNDryYYY mom OIYYYYLIMITS
X COMMERCMLGENEMLLMILM EACHOCCURRENCE S 1.000,000
CLAIMS-MADE �OCCUR P0.EWSE5 6Cau y 100'000
MED UP(AW am L t6'000
A SKSW903321 oVSOr201S 04/302019 PERSONALEADVINJURY 11.000'000
G IN L AGGREGATE LIMIT APPLI ES PER'. GENERAL AGGREGATE f 2'OOD'DW
X POLICY OJEC ELOD PRODUCTS-COMPAX AGG S 2.000.000
OTHER: S
AUTOMOBILE UABIIII'Y Ea ISN aI'ISL
S 1.GOD,DW
ANYAUTO BO.1IWURY(Per N-Ar) I
B OWNEDAUTOS X SCHHEEOO,IILED BW6903321 OG302018 04/302019 BORRYINIIIRYtPeravldmn I
X HIRED NONLOWNED
AUTOS ONLY X AUTOSONLY PROPII NA E E
X UMBRELLA LM OCCUR EACH OCCURRENCE 15•�O'0S
C EXCESS LNO CLAIMSMADE US056903321 04/302018 04(402019 AGGREGATE 15'090'000
DED X RETENnON3 10'000 I
RNF.RS COMPENSAn011 R TN
WD
AND EMPLOYERS'MAULTY YIN X STATUTE Efl
C
ANY PROPISETOMPARTNERgFCUTNE ❑N xu XW056903321 DG302018 04/302019 EL EACBACCIOENT 11'000.000
FIOERIMEVBENr PUDE) 1.000.000
(Aaa.bry In Nm EL.DISEASE-EAEMPLOYEE $
dMorbiurser 01.000.000
ORIPTION OF OPERATIONS Arm E1.DISEASE-POLICYLIMIT $
DESCRIPTION OF OPERAIMNS I LOCATIONS I VEHICLES(ACORD tet,Adda.ralR..SUMNI.B.aui a tlli Imae ep—X rpulMl
Proof of Renewal Insurance.COVemge o rot guaranteed beyond IM dab of this form unless w6 ied by the agency of rewrd With an updakd
cer if ate Of insurance upon m91reM.
CER I IHCA I E HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Action Air.'Be. ACCORDANCE WITH THE POLICY PROVISIONS.
P.O.Coe 636
AUTHORESS REPRESENTATIVE
FINA1,Hills MA 01030 la"Q
4L�F.GC
®1988.2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016403) The ACORD name and logo are registered marks aACORD
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