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The Commonwealth of Massachusetts
Department of Industrial Accidents
41Pr Office of Investigations
C; 1 Congress Street, Suite 100
Boston,MA 02114-2017
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WWW.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / �] Please Print Legibly
Name (Business/Organization/Individual): AZYN. f?'1 l- r,A ll€- -'t i''/e; - L _
Address: 1 �/ L"s(, . l` -t✓
City/State/Zip:�„�' S7-�i � =f J`f , 17`-7!Jl9'F'c' Phone#: l 75. 67 7_ / `f/6
Are y u an employer? Check the appropriate box: Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I
6. ri New construction
employees-(full and/orart-time).* have hired the sub-contractors
p
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'
9. 111 Building addition
[No workers' comp.insurance comp. insurance.+
required.] 5. ❑ We are a corporation and its 1O.n 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 13 Other t""� `
employees. [No workers'
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.
Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 46V47 t:*tkA, i 6'+' n-,''C = PiLA-r u�.c— 1�—���- t° ,
Policy#or Self-ins.Lic.#: 1/lr C ( ' C+i > Expiration Date: ) T�
Job Site Address: e75 19,6 4 rkD/(s City/State/Zip: t-` [e,
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi u er the pains nd penalties of perjuly that the information provided above is true and correct.
-- S
Signature:
Date:I
Phone#: e07—/V/
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone If:
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INSURANCE COVERAGE: ,��
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes No❑
If you have checked Y_ELS,indicate of coverage by checking the appropriate box below:
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee rinPC not have$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 ❑
Signature of Owner or Owner's Agent
By checking this box0, 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 Tncpertions
Date Comments
Final Incpertinn
Date Comments
Type f License:
By L"J Master
Title ❑ Master-Restricted
City/Town
❑Journeyperson Signature of Licensee
Permit# ��
❑Journeyperson-Restricted
Fee$ License Number:
0
Check at www macs gnv/rlrl
Inspector Signature of Permit Approval
JUN 20t Commonwealth of Massachusetts
ii
City Of Northampton
DEPT. R HAMPT G,MA . 0 — ( 3 r�
NORTHAMPTON,MA� Sheet Metal Permit 3
ate: • Permit# S1n '
Estimated Job Cost: $ j 5-00, 00 Permit Fee: $ / G 01f - 26
Plans Submitted: YES NO ✓ Plans Reviewed: YES NO
Business License# 533 Applicant License#
Business Information: Property Owner/Job Location Information:
Name: Qn�N_S/2P �P -( Name: ne7'7'f- _ /K 11-
Street: NO wes1"5 &r Street: 950 J 7 k2l /1
City/Town: kleS114-1 R�� (G City/Town: errCsie..ii�,pJ 4 0(06/
Telephone: (113 -V)7-/'fl Telephone:
Photo I.D. required/Copy of Photo I.D. attached: YES NO
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
V 10,000 s
Square Footage: under 10,000 sq. ft. over 10, sq. ft. Number of Stories:
q
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:
/e-c, fc9 f&c e :c cfc,tollaork-vvdr k 50".-7 e ctree0-
1 r - e— At IS -ye 7`.
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-2013-0063
APPLICANT/CONTACT PERSON AARON MORIN
ADDRESS/PHONE 140 WEST ST (413)247-0550 0
PROPERTY LOCATION 95 PIONEER KNLS
MAP 29 PARCEL 565 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 140,4/ Z 'U2`6—
Fee Paid
Typeof Construction: RELOCATE 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 FOL WING 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
� � lm Street Commission Permit DPW Storm Water Management
,tid ..AotIldi l—/4 —/Y
Sigriiiiire—of Buil.ing •fficial 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.
95 PIONEER KNLS SM-2013-0063
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
GIS#: 15273 T
Ma 29 '
Bloc 565
k SHEETMETAT, PERMIT
tot: 001
Permit_ SHEETMETAL ` T£RCENTE41,2-
Category: renovation
Permit# SM-2013-0063 PERMISSION IS HEREBY GRANTED TO:
Project# JS-2013-001864
—
Est. Cost: $2,500.00 Contractor: License:$2,500.00 Expires:
--- — -
Fee Charged:$25.00 AARON MORN Sheetmetal-533 10/28/2013
Balance Due:$.00 Owner: KING SCOTT A&CHERYL A
#of Fixtures: Applicant: AARON MORN
DigSafe# AT: 95 PIONEER KNLS
UseGroup
ConstClass
ISSUED ON: 11-Jun-2013 AMENDED ON: EXPIRES ON:
TO PERFORM THE FOLLOWING WORK:
RELOCATE 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-2013-006602 07-Jun-13 1608 $25.00
212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck @northamptonma.gov
GeoTMS®2013 Des Lauriers Municipal Solutions,Inc.