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32C-040 (4) fir. M 3;0 r D 44 o A 1" (fl V)i , u, m ° Z CM w D -I c a"1 cj fn 0 --I -4 m n m ,.., I mm W r. X c Z > 1 Z =T330 cr-Z O Z m3 r "C r �t D- � m. m > 0 Cu © Z �A D m --' m .�_m z w> w co 14 o t 0 0 (J) r C: C o Signature pro r a wua c' t 'rI x S A ,._ ya m� 5" oy ` 9,g: s 9 Zm ° w a CI) o ;-2�g m�3 11 % _r .p N I I I L ( rant:roan The Commonwealth of Massachusetts - Department of Industrial Accidents i -“----trt Office of Investigations s' �� 1 Congress Street, Suite 100 1 Boston,MA 02114-2017 T. '- www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I� r Please Print Legibly Name (Business/Organization/Individual): Nr-CYk. i L o r`A S/tt2.4-7 C•�7e'• '�-L — Address: I 6(6-' LA./4. 7` 5 e,r— City/State/Zip:Li S A d / ;;'2� / ' c'�Phone#: 3. : f Are an employer? Check the appropriate box: Type of project(required): 1. I am a with w employer 4. ❑ I am a general contractor and I 6. n New construction employees(full and/orpart=time).* have hired the sub-contractors 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. n Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp.insurance comp.insurance.+ requi 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions red.] 3.❑ I am a homeowner doing all work officers have exercised their 11.11 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roofrrepairs insurance required.]u t c. 152,§1(4),and we have no q ] 13.ErOther -• " ✓�'-r employees. [No workers' comp.insurance required.] *Any applicant that checks box#tl 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: �L cc't L t '�` ''��' /It ' "�- -.•�-./7. ` `- i Policy#or Self-ins.Lic.#: (4;6_ ( / O IOd Expiration Date:)"� �I Job Site Address: l 7 — + Dr City/State/Zip: , /i1oU ^/ ItiO/766 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi uj der the pains and penalties ofperjuiy that the information provided above is true and correct. Simature:—(� //�./_ Phone#: z l ?7 '�l 7 r - Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: tifn Wic4 INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy I ' Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee rInac not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waivpsthis requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Inc Pros eSS n�prtinnc Date Comments Final Incppetinrt natP rnmm'nts Type of License: By ❑ Master Title ❑ Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: Fee$ ❑ Check at www mace gnv/rirt Inspector Signature of Permit Approval RECEIVED Mgt r 9 2013 Commonwealth of Massachusetts DE=PT OF BUILDING INSFFCTiONS City Of Northampton. NORTHAMPTON,MA 01060 Date: L/ _5-- r Sheet Metal Permit Permit# 59 /3S7 Estimated Job Cost: $,. 87:04 Ot Perml°4: So Plans Submitted: YES NO s ' Reviewed: YES NO Business License# 53 3 Applicant License # Business Information: / _ Property Owner/Job Location Information: Name: -A I h "' t� SI- - Name: V k'S v& / ,_—.4 Cr, Street: lefol, sf swy_e* O( D Street: "/7/ `4--Ye S' City/Town: Wes-f"/ `F- (r City/Town: /7 4114.4-10/ Telephone: :((3 _`7 2--/c// 6 Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES 1./.-----1\10 Staff Initial J-1 /M-1-unrestricted 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 Square Footage: under 10,000 sq. ft. Zo—v—er 10,000 sq. ft. Number of Stories: Sheet metal work to be,,completed: New Work: . Renovation: HVAC V. Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: 74 6./1 e i Sf. 1( , 1 ° st CCcwtPioc 1-e___ t-A e-r r-e_ a&P c1 '1 , Sec i- b n S C/ ,CC +© 1-e re --i-D -- Se 0 rig+ . 000 ce t, v , 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 File#SM-2013-0051 APPLICANT/CONTACT PERSON AARON MORIN ADDRESS/PHONE 140 WEST ST (413)247-0550 0 PROPERTY LOCATION 47 PLEASANT ST MAP 32C PARCEL 040 001 ZONE CB000)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Aol lL 0 Fee Paid (o T Typeof Construction: MODIFY DUCTWORK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 533 3 sets of Plans/Plot Plan THE FO NG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN ATION 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: 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 - from Elm Street .,mmission Permit DPW Storm Water Management ... 1( 5///'/,, Si re of B il.in! Offi ial 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. 47 PLEASANT ST SM-2013-0051 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON GIS#: 10097 /oaSHAMPT� Map: 32C �' Block: 040 +��—�� . Lot; 001 ��(; , � SHEETMETA PERMIT Permit: SHEETMETAL 4 �£R�EN?ENP�+ Category: renovation Permit# sM-20 13-0051 PERMISSION IS HEREBY GRANTED TO: Project# JS-2013-001530 License: ,Est. Cost: $2,880.00 Contractor: Expires: Fee Charged:$50.00 AARON MORIN Sheetmetal-533 10/28/2013 Balance Due:$.00 Owner: COOLIDGE CENTER LLC C/O JEFF DWYER INC r #of Fixtures: Applicant: AARON MORIN 1DigSafe# AT: 47 PLEASANT ST IUseGroup LConstClass ISSUED ON: 11-Apr-2013 AMENDED ON: EXPIRES ON: TO PERFORM THE FOLLOWING WORK: MODIFY DUCTWORK 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: Sheetmetal REC-2013-005442 09-Apr-13 1564 $50.00 212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck @northamptonma.gov GeoTMS®2013 Des Lauriers Municipal Solutions,Inc.