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32A-148-009 SM-2023-0001 30 PLEASANT ST UNIT 4 COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 32A-148-009 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-2023-0001 PERMISSION IS HEREBY GRANTED TO: Project# SHEET METAL 2023 Contractor: License: Est. Cost: 10000 ACTION AIR INC Const.Class: Exp.Date: Use Group: Owner: TRUSTEE SHERIDAN KIMBERLY A Lot Size (sq.ft.) Zoning: CB Applicant: ACTION AIR INC Applicant Address Phone: Insurance: P O BOX 636 (413)789-9305 WC9080919 FEEDING HILLS,MA 01030 ISSUED ON: 01/20/2023 TO PERFORM THE FOLLOWING WORK: HVAC 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: 'fil i� Fees Paid: $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner Commonwealth of Massachusetts City Of Northampton Date: I! (3 /a3 Sheet metal Permit Permit #M-- Estimated Job Cost: $ 16,(5oo Permit Fec: $ C/d1) Plans Submitted: YES NO 2S, JqN /,9 Plans Reviewed: YES NO h T OF Business License# o<�rtiaMn!ti�l! licant License # _ onr Spy �'�_`41q n y CTli1al�, Business Informatio�nl: PrdPerfy Owner/Job Location Information: Name: &jic,4 4(re_ c3 Name: ea i 1 li K p r So Street: ,l/ T ucs/x(e4/ CGne Street: 30 Pku 01 I S4 City/Town: (3Q'tU Mrq- O JEO/ City/Town: /00A.1 it iv/id 464 r)1/J O X)(000 Telephone: (7/3- 7 qi - 9305 Telephone: /- 71 g- (p g7 -31./D, Photo I.D. required/ Copy of Photo I.D. attached: YES k NO Staff Initial J-1 ateti nrestricted 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 X 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: Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: nSktniI(c1 ft4oyk o-� Sp►coo dua-i n 2 eoYriodeI C� 6tulitoom . o h -c 5 hood .ocaQ115` 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, $100.00 Commercial INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yell No 0 iC I If you have checked Yes, indicate the typo of coverage by checking the appropriate box below: A liability insurance policy Other type of indemnity El Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee Tinos not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application walvnsthis requirement. Check One Only Owner El Agent El Signature of Owner or Owner's Agent By checking this box❑, I hereby certify that all of the details and Information I have submitted(or entered) regarding this application aro true and accurate to the best of my knowledge and that all sheet metal work and Installations performed under the permit issued for tlfIs application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Progress Incrections,, Date Comment t Final jncrrrtinn Doti' Fnmmentq Type of License: By ❑ Master iiiii_igen.... Title ❑ Master Restricted ` City/Town ❑Journeyperson Signature of Licensee • Permit# / I�n ❑ l/ Journeyperson Restricted License Number: Yll C// Fee$ ❑ Check at www mass rgnvlripl ,V6fT1/ 1M D2 Inspector Signature of Permit Approval • The Conrnron►vealth of Massachusetts III -tom Department of Industrial Accidents t:=, 'ail 1' Office of,lnr.es.t;gations - - • , , .y '- 6(JU if ashlnston Street IL0,l,,,_l Boston, MA 02111 n''' 0. •u.s., wwu'.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A.pplicantjnformilion Please Print Lefibjy Name (Business/Organization/Individual): 4 vlu/t._ 4 _._..J�.0_ l• •� _ Address: 1l I Tirt114Stil,Ct t_i /_‘;910 ._ Ci /State/Zi.: ��/i , ')A, l�(�( 11//l Phone #: L;/ 2U �� ' Are yo a employer?Check the appropriate box: Type of project(required): 1. I am a employer with e' 4. 0 I am a general contractor and 1 employees (full and/or part-time). * have hired the sub-contractors 6, 0 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship 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. 0 We arc a corporation and its 10.0 Electrical repairs or additions 3.0 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 bclot+ showing(licit 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 stale 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: �t 0 4--1 a__ ,,,.9/j71,0 L(dal) Policy#or Self-ins. Lic. #: SI 01 I 5- t,) i stir` 9!)k09/ Expiration Date: W565/02 Job Site Address: 5fP &(% LPi( Six II f, ,6 City/State/Zip: /)6C46,/f/m o`( /,i 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. "do hereby cern' /der the pain n enalties perjury that the information provided above istrue and correct. natt,re: / 1 ' Date: /13 7? Ph Me#; (_/ -- 2F l/ - Qo's------ IOfficial 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_ • _..—" ACTIAIR-02 .JBDID9, AFRO' DATs(MMIDD/1'Yrv) CERTIFICATE OF LIABILITY INSURANCE ��1QAM 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 poiicy(les)must have ADDITIONAL INSURED provisions 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 lieu Of such endorsement(s).,, PRODUCER QONeCT Berkshire Insurance Group a Division of Brown&Brown �A"A�Y PHONE Rao:(866)636 0244 j 413�,447 19 T PO Box 488D ,No)1� __ Pittsfield, MA 01202 INOIJRERIBI AFFORDING COVERAGE /WOO , INSURER Ai SELECTIVE INSURANCE GROUP INSURED INS a,Selective Insurance Company of South Carolina _ 19219 Action Air,Inc. INSURER C L PO Box 636 INSURER Di.___ Feeding Hills,MA 01030 INSURER E i INSURER F; COVERAGES CERTIFICATE 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. 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADM SUBR POLICY NUMBER POLICY EFF POLICY EXP LTR kIBD MILL ,JMMIDDIYYYYI IMM/DDKYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY 1,b00,000 EACH OCCURRENCE S CLAIMS-MADE X OCCUR S2381584 4/30/2022 4/30/2023 pRAAETI ES IFJENTEF.a cb1 $ 600,000 MED EXP(Arry one own) I �t5,000 PERSONAL&A INJURY $ 1,000,000 OV GE 'L AGGR AIE LIMITAP S PER, 2,000,000 POLICY DCl LIMI LOC GENCRALAGORCOATE __I_ 2,000,000 J T PRODUCTS-COMP/OPAGG $ _ OTHFR• $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea act-Mani) $ ANY AUTO A9107185 4/30/2022 4/30/2023 BODILY INJURY(Per Doreen) $ OWNED UTU EO�SDONLY X SCHEDULED BODILYO INJURYp (Per accident) $ X AUTOS ONLY X AUTOS ONLY (Perr accider tI AMAGE $ . $ A X UMBRELLA IJAB X OCCUR EACH OCCURRENCE $ 6,000,00( EXCESS LIAB CLAIMS-MADE S2381584 4/30/2022 4/30/2023 AGGREGATE $ 5,000,00( DED RETENTION$ A WORKERS COMPENSATION D EM PLOYERS'RS'LIABILIITY X Y/N IMTUTE O'TH AN ANY PROPRIETOR/PARTNER/EXECUTIVE WC9080919 4/30/2022 4/30/2023 1,000,00( OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT - $ (Mandatory In NH) 1,000,00( If es,describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,001 A Owners&Contractors S2381706 6/15/2022 6/15/2023 Aggregate 2,000,00( DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached H 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 Action Ai Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ac r, Ac Box 6 ACCORDANCE WITH THE POLICY PROVISIONS. Feeding Hills,MA 01030 AUTHORIZED REPRESENTATIVE l At nort 9K/'n1R/ns1 ©1988-2015 ACORD CORPORATION. All rights reserved • , A:eta .4' ' "` I .1 'l IIt ), �i u irl ' .114 '�' in i r ' 1 i`1 Y4• `( ' 11 III J' t '' �/f�t11.d� i 1 1 P, ...,3S'e=7i'� .13111rd#3 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 CHEVALIER z 111 INDUSTRIAL LANE • AGAWAM, MA 01001 Z W U 6849 08/28/2024 352616 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER