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16A-035 (2) SM-2024-0009 95 CHESTERFIELD RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 16A-035-001 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-2024-0009 PERMISSION IS HEREBY GRANTED TO: Project# NEW HOUSE 2023 Contractor: License: Est. Cost: 5000 ALL SEASONS HEATING AIR Const.Class: Exp.Date: Use Group: Owner: BECCA CONSTANTINE, Lot Size (sq.ft.) Zoning: Applicant: ALL SEASONS HEATING AIR Applicant Address Phone: Insurance: 93 ELM ST (413)247-9842 WCT6529S HATFIELD, MA 01038 ISSUED ON: 02/09/2024 TO PERFORM THE FOLLOWING WORK: INSTALL DUCT WORK FOR ERV SYSTEM 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: Fees Paid: $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner gwRil Commonwealth of Massachusetts Sheet Metal Permit Date: 1 3 r <} [ [EcEwELPermit# 5J ' 5 Estimated Job Cost: $ O. FE8 hermit Fee: $ �57! - 8 2024 Plans Submitted: YES NO Pl s viewed: YES NO Fl I tv FlTFfi OFCuanwc 15vtk1 rl Pemit p Business License# ?��{'I( r' ' a�?t'Tov. i Littense# p - adr 3 l a r Business Information: Property Owner/Job Location Information: v cfc:,sons Name: l-Af ►)C Air a; r -hon.,n9 Name: P Crcc eons--an-f;t e Street: C J Fl rrn Street: Q6 Ches•+er A'ec( Qd City/Town: 't-AC , t`4 C.�1C� City/1 own: �-P 2cic Cr)) r a. Telephone:(c ) -1 13- Lea 1 . ',L, Telephone: 41 • a--34 q s Photo I.D. required/Copy of Photo I.D. attached: YES NO Staff Initial J-1 /restricted 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 v'Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. Number of Stories: a Sheet metal work to be completed: New Work: / Renovation: HVAC 1 Metal Watershed Roofing Kitchen Exhaust System Metal Chimney /Vents Air Balancing Provide detailed description of work to be done: I nS'1-C.lkov-hcn OF clvC- \Ain '-or EPA/ �IISiaGlva_ CaO ( > ci, 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 type of coverage by checking the appropriate box below: A liability insurance policy,.❑ Other type of indemnity ❑ Bond ❑ 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 waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box !hereby certify that al!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 Progress Inspections Date Comments Final Inspection Date Comments Type of License: By Master Title / ‘ ��✓ / ❑ Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: Fee$ ❑ Check at www.mass.gov/dpl cfuzilk TAT,/ Inspector Signature of Permit Approval A ® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 01/31/2024 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 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 CONTACT Jennifer Ellinger NAME: Aquadro&Associates PHONE (413)586-7373 FAX (413)584-0859 (A/C,No,Ext): (A/C,No): 355 Bridge St.,P.O.Box 357 E-MAIL jenn@aquadroinsurance.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01061 INSURER A: Travelers Indemnity Co of CT 25682 INSURED INSURER B; National Grange Mutual Insurance Company 14788 All Seasons Heating&Air INSURER C: 93 Elm St INSURER D INSURER E: Hatfield MA 01038 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2362210930 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 I 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGRENTED CLAIMS-MADE X OCCUR PREM SESO(Ea occurrence) $ 300,000 MED EXP(Any one person) $ 5,000 A 6801G505644 07/10/2023 07/10/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO 2000,000 JECT LOC PRODUCTS-COMP/OP AGG $ , OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ B OWNED v SCHEDULED M1T6529S 07/10/2023 07/10/2024 BODILY INJURY(Per accident) $ AUTOS ONLY •/� AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY _ AUTOS ONLY (Per accident) EPLUS $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? Y N/A WCT6529S 07/10/2023 07/10/2024 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN JDR Builders ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 66 AUTHORIZED REPRESENTATIVE / it,Ai,Whately MA 01093 i a I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): All Seasons Heating & Air Conditioning Address: 93 Elm Street City/State/Zip: Hatfield, MA 01038 Phone#:413.247.9842 Are you an employer?Check the appropriate box: Type of project(required): I.Q I am a employer with 8 4. ❑ I am a general contractor and I 6. ['New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling 2.❑ 1 am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' p n # 9. ❑ Building addition [No workers' comp. insurance comp. insurance. 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 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ 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 below 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 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 Company Policy#or Self-ins. Lic. #: WCT6529S Expiration Date: 07/10/2024 Job Site Address: 95 Chesterfield Road City/State/Zip:Leeds MA 01053 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 certify lid, he ins a penalties of perjury that the information provided above is true and correct. Signature: ll — Date: 01/31/2024 Phone#: 413.247.9842 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 3.DCity/Town Clerk 4.0 Electrical Inspector 5.1=IF'lumbing Inspector 6.0Other Contact Person: Phone#: