38A-107 (2) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, Mass. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business /Organizatio dividual): 4 c11 1on 0 I r _._l -ri 0 -
Address: �.Q . q (.s' 1 ---
City /State /Zip: e t y q I L I (S (\i 4 Phone #: q 7 7E H306
A ou an employer? Check the appropriate box: Type of project (required):
I am an employer with I 4. 0 I am a general contractor and I 6. 0 New construction
mployees (full and/or part time).* have hired the sub contractors ❑Remodeling
2. 0 I am a sole proprietor or partner- listed on the attached sheet.
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 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 perm MGL
insurance required] t c. 152, § 1(4), and we have no 12. ❑ Roof repairs
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.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
;Contactors that check this box must attach an additional sheet showing the name of the subcontractors 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: Y wiG(,iK O I �. _.11 �,;� vvo
ll I�(,(✓'Y7 0 oo, l/�
Policy # or Self -ins. Lic. #: (LC -7 4 7 I q t/�f I to Expiration Date: , 7j�3 q / ?j
Job Site Address: ,,_ , 1 I. UI 1) io q e 14;11 E. City/State /Zip: Ceighaill p'ILiIi 4—
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 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage ve - ication.
I do herby cert' nder the i s ' ' p • - ies of p ury that the information pro ided above is true and correct.
Signature: a� Date: /D/3/ 13....
Print Name: dip,, /Y - et)14 -1_ r' Phone #: 1r 3 p - , �,
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 Heath 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 type of coverage by checking the appropriate box below:
A liability insurance policy (_ Other type of indemnity ❑ Bond El
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❑, 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
Progress Inspections
Date Comments
Final Inspection
Date Comments
Type of License:
By ❑ Master
Title
///(ie; 1=1 Master Restricted City/Town i 0
❑Journeyperson Signature of Licensee
Permit #
❑Journeyperson Restricted License Number: - 211
Fee $
❑ Check at www.mass.govidpl
Inspector Signature of Permit Approval
RECF
V gt
h. —7 Commonwealth of Massachusetts
2 2012 Sheet Metal Permit
DEPT. OF SlitLow
NORTHAW4 j Permit # 13-,2&
Estimated Job Cost: $ )&5 ) 00C) Permit Fee: $ \ne C 41
Plans Submitted: YES k NO Plans Reviewed: YES NO
Business License # Applicant License #
Business Information: Property Owner / Job Location Information:
e4(e.s
Name: \o
5(- Au- /14.(A) 144121""L -1Cji°
e ti`b Aio ezAbe_
a
Street: Ro * (D,31/ Street: Name: _
City/Town: re e y it; Os City/Town:
Telephone: vi,3-7 ' 43&5 Telephone:
Photo I.D. required / Copy of Photo I.D. attached: YES NO
Staff Initial
J-1 /-1-unrest
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. over 10,000 sq. ft. Number of Stories:
Sheet metal work to be completed: New Work: X Renovation:
HVAC Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney / Vents Air Balancing
Provide detailed description of work to be done:
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du ed, inq dyw 11/9-1401 L,d) el-0z° 5p /as
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it VI/ oV/1 si KS 671 d h
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File # SM- 2013 -0026
APPLICANT /CONTACT PERSON ACTION AIR
ADDRESS/PHONE P 0 BOX 636 (413) 789 -9305
PROPERTY LOCATION 11 VILLAGE HILL RD
MAP 38A PARCEL 107 001 ZONE PV(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ` __Qp
Fee Paid JJ``ff'"'ZZ
Typeof Construction: INSTALL 8 SPLIT SYS & DUCTING,2 DUCTLESS,ERV & ROOF MOUNT EXHAUST Di
New Construction I � Non Structural interior renovations Jv
Addition to Existing /1//e Jt
A ccessory Structure
Building Plans Included:
Owner/ Statement or License 7110
3 sets of Plans / Plot Plan
THE FOL ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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
Pc ' j- m Si eet Co • sion Permit DPW Storm Water Management
Si a e of Building 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.
11 VILLAGE HILL RD - THE GATEHOUSE SM- 2013 -0026
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
tHAMp
GIS #: 11835 7-0
Map: 38A
Block: log -, -- (IMO SHEETMETAL PERMIT
Lot: 001
Permit: SHEETMETAL *r.,;,- -�y
Category: SHEETMETAL
Permit # SM-2013-0026 £RCENTENP
PERMISSION IS HEREBY GRANTED TO:
Project # JS- 2013- 000664
Est. Cost: $ Contractor: License: Expires:
Fee Charged: $50.00 ACTION AIR Sheetmetal - 7110 06/28/2012
Balance Due: $.00 Owner: NEW HARMONY PROPERTIES LLC
# of Fixtures: Applicant: ACTION AIR
DigSafe # AT: 11 VILLAGE HILL RD - THE GATEHOUSE
lUseGroup
� ConstClass
ISSUED ON: 05- Nov -2012 AMENDED ON: EXPIRES ON:
TO PERFORM THE FOLLOWING WORK:
INSTALL 8 SPLIT SYS & DUCTING,2 DUCTLESS,ERV & ROOF MOUNT EXHAUST - *NEED AS BUILT PLANS*
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
Fixtures:
Floor: Type: # of Fixtures Floor: Type: # of Fixtures
Fee Type: Receipt No: Date Paid: Check No: Amount:
Sheetmetal REC- 2013 - 001778 02- Nov -12 1097 $50.00
212 Main Street, Phone:(413) 587 -1240, Fax:(413) 587 -1272, Email :lhasbrouck @northamptonma.gov
GeoTMS® 2012 Des Lauriers Municipal Solutions, Inc.