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14-002 (3)
SM- 022-0022 1051 CHESTERFIELD RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 14-002-001 CITY OF NORTHAMPTON Permit: Sheet Metal PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# SM-2022-0022 PERMISSION IS HEREBY GRANTE,1 TO: Project# RENOVATION Contractor: License: Est. Cost: 12000 ACTION AIR INC Const.Class: Exp.Date: Use Group: Owner: COLLIN HAYES Lot Size (sq.ft.) Zoning: WSP Applicant: ACTION AIR INC Applicant Address Phone: Insurance:, P O BOX 636 (413)789-9305 WC9080919 FEEDING HILLS,MA 01030 ISSUED ON:10/05/2022 TO PERFORM THE FOLLOWING WORK: HVAC FOR FURNACE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: . Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: III 9 I � • r i Ii Fees Paid: S50.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner Commonwealth of Massachusetts City Of Northampton Date: 9 )I y fac)-- she-(00•- .: -ermit Permit# �"1 �� a' 03 • { 1, Estimated Job Cost: $ / ermit Fee: $ 6 at Cr I LID SEA 33 Plans Submitted: YES NO ‹Ol$ans evifred: YES NO Business License# bEpj oFsur��, cen # MA 010 RTHAMPTON, SPECT60IONS I Business Information: Prope ner Job Location Information: '''^, /� \I^� ' ' Name: Uy( l: roc Name: ii pc LG/ Street: 111 S lnd u S4-►(�C,,� �,(VI e Street: )0 51 ��IPS/,ir'e P iP 1 � &X/ City/Town: a u3a � 0 t (� City/Town: Leeds f I I' 0 Telephone: ! ? -7?mil 9 3OS Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES Y - NO gl0 Staff Initial J-1nrestricted 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: Off✓✓✓✓ice Retail Industrial Educational InstitutioK al Other Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: Renovation: HVAC K Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: 16(Dtk liCt.4 ►0 o-- du a_i_ cc ,tptiviA -e_ustdrtCy 4tiome 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, $100.00 Commercial INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Ye ❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑ Other type of indemnity El Bond El OWNER'S INSURANCE WAIVER: I am aware that the licensee rtnas not havp the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waivasthis requirement. Check One Only Owner ❑ Agent El Signature of Owner or Owner's Agent By checking this box❑,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO PrngrPcc lncpprtinn� Tate Cnmments Final IncrPctinn Date Comments Type of License: By ❑ Master Title ❑ Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# DJourneyperson-Restricted / � Fee$ License Number: l� El Check at www mass gnv/dpl 1‘ I 0/5/0 Inspector Signature of Permit Approval The Commonwealth of Massachusetts Department of Industrial Accidents Y -M t VAN vumme f/ Office ofInt'e figalions . _ _ _ with - dUU ii��tshingtun Street • Boston, MA 02111 -7`'•:.I��• www.mass.gov/dia _ Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print Legibjy, Name (Business/OrganizationMdividual): 4e,V.4 iX .fit 17a_ Address:_ If/ 2--- 1./ci/Q -• / . City/State/Zip: (,/(,(�(y I4/( /i Phone #: /,3-- Are you au employer?Ch ck the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and 1 employees(full and/or part-tune). « have hired the sub-contractors 6. 0 New construction 2.❑ I am a sole proprietor or partner- . listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' corn insuruncc.t 9. El Building addition [No workers'comp, insurance p required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.El I am a homeowner doing all work officers have exercised their 11.0 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 bclou 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 tub-contractors and state whether or not those entities have' employees. lithe 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: ,ILJ?J C e_ t_ Vic(,( ](' (C Policy#or Self-ins. Lic.#: 1iJY! qo rO 9/ 9 Expiration Date: V/J6 f 02-3 Job Site Address: JO SI alien t'clf/d �d t City/State/Zip: X2Pric MA 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 c fy under the pa' a d enalt'ies perjury that the information provided above is true and correct, Siakture: Date: `110111 Ja-. i 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: n'., 44. DL }F S�� h / '^1" y/` '• �•4 ,. DFJvE LICENSE ;.Clxs:d a:Raah.'NONE ..Eedon;NONE ;:, ,.11C«: A8937.9563 M m. tr t s Dos: 4)8 1 .1965 IsEye.:gL *2023 CHEVALIER zPAUL JEAN LOtUIS 132 RANDALLDR . SUFFIELD C;06078-t 4 • ..ksi..449-09-2016 �.-41 ACTIAIR-02 1B0112Q AC-G Rv- CERTIFICATE OF LIABILITY INSURANCE DATE(MM/OD/YYYY) 6/19/2922 . 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 have ADDITIONAL INSURED provIsi ns or 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 Ileu of such endorsement(s), PRODUCER CONTACT Berkshire Insurance Group a Division of Brown&Brown PHONE A No E,,,) (866)636-0244 FAX Ma N0:(413)447-1977 PO Box 4889 Pittsfield,MA 01202 _ has: INSURER(S)AFFORDING COVERAGE NAIL If. _ :N�rrRFo • ELECTIVE INSURANCE�GROUP INSURED INSURERS:SelectIve Insurance Company of South Caroline 19269 Action Air,Inc. INSURER C: PO Box 636 INSURER CI; Feeding Hills,MA 01030 INSURER s: , INSURER F: COVERAGES CERIIFICATE NUMBER; 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. NOTVNTHSTANDING 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 PAIDA CLAIMS. ILTR TYPE OF INSURANCE ADDL SUBR40 POLICY NUMBER —.(MMIODIYYYY� (MMInfIYYY) UNITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 J CLAIMS-MADE X OCCUR S2381684 4/30/2022 4/30/2023 DAMAGE S!TO Ea R nrr�.rnnoal ,l ENTED 600,000 PREMISE MED EXP(Any one , s 16,000 _ PERSONAL&ADV-1N rJI I $ 1,000,000 GEN'LAGGR A LIMIT APP I SPER GENERAL AGGREGATE J j 2,000,000 POLICY jP& II LOC PRODUCTS-COMP/OP A 9 1 2,000,000 OTHER s B AUTOMOBILE LIABILITY (E MacB ideeDISINGLE LIMIT , 1,000,000 ANY AUTO A9107185 4/30/2022 4/30/2023 BODILY INJURY(Per Dorm) J OWNED ONLY X AUUTNOSSyUyL�EEDp BODILYO INJURYp (Per $ X AUTOS ONLY X AUTOS ONLY PPerr acECidontl AMAGE S S A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE - 6,000,000 EXCESS LIAB CLAIMS-MADE S2381584 4/30/2022 4/30/2023 AGGREGATE s 6,000,000 DED RETENTIONS S A WORKERS COMPENSATION X PER I QII' AND EMPLOYERS'LIABILITY ,I1.(�i,� WC9080919 4/30/2022 4/30/2023 STATUTE �R I 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE I I N/A E.L.EACH ACCIDENT $ �FFICER/MEMNH)EXCLUDED? 1,000,000 iAandatory In NH) E.L.DISEASE-EA EMPLOYF,F, $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S A Owners&Contractors S2381706 6/15/2022 6/15/2023 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Proof of Renewal Insurance Coverage is not guaranteed beyond the date of this form unless verified by the agency of record with an updated certificate of insurance upon request. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Action Air,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 636 Feeding Hills,MA 01030 AUTHORIZED REPRESENTATIVE C ash 1 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. Th. ACf1Rr1 name,anrd Innn arcs rmnistarpri marks of ACORD Please visit our web site at http://www.mass.gov/dpl/boards/SM PAUL J CHEVALIER 111 INDUSTRIAL LANE (SM) AGAWAM,MA 01001 Fold,Then Detach Along All Perforations `COMMONWEALTH OF MASSACHUSETTS DIVISION OF OCCUPATIONAL LICENSURE BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE MASTER-UNRESTRICTED PAUL J CHEVALIERo 111 INDUSTRIAL LANE W AGAWAM,MA 01001 W U J 6849 08/28/2024 352616 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER