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18C-090 (6) Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hint, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or morn of the foregoing engaged in a joint enterprise,and including the legal Telvesentatives of a deceased employer,or the receiver or trustee of on individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152.§25C(6)also states that"every note or local licensing agency shall w•ithbold the issuance or renewal of a license or permit to operate a business or to construct builder is the commonwealth for may applicant wbo has not produced acceptable evidence of compliance with the insurance coverage requited." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if nay,supply sub-contractors)names),addresses)and phone numbu(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. if an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit 'Ile affidavit should be returned to the city or town that the application for the permit or license is being requested,sot the Department of Industrial AaadentL Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurancc license number on the appropriate line. City or Tows Olfmisis Please be sure than the affidavit is complete and printed legibly. 7be Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fil)in the permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is an file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Wfi a of Investigations would like to thank you in advance for your cooperation and should you have any questions. please do not hesitate to give�K■_ron, The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of InveWptioms 600 Washington Street Boston, MA 02111 Tel. #617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 wised 424-07 www.mass.gov/dice The Commonwealth of Massachsaelts Department of Industriid Accidents Offke of Investigations ,yr 600 Washington Sired Roston,MA 02111 wwty mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumhers Applicant Information Please Print Legibly Name(BusinessMTganintim%dividual): c �-- r Address: City/State/Zip: t�lei o�O i 9' Phone#: (3 t C;�7—/ I A,ree you an empkryerm. awck the appropriate bo= Type of project(required): 1.1J I am a employer with 1 4. [] 1 am a general contractor and 1 employees(hil)and/or part-time).' have hired the sub-contractors 6. 0 New construction 2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-con t acton have g- ❑Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp.insurance gyp• . requirc] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 3. lam hem�doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. '�P 12.0 Roof repairs insurance required.]t n 152,§l(4),and we have no employees.[No workers' 13.0'Other Qc�t�iQ✓lrs,a�/r comp.insurance required.] •Any MWI, m that checks ban 01 usual also fill out the section below drown thworkers'en worke conWenmion policy infomtatkW T Honmawncn wbo sttbmm this ttf6iwit wxlx tma dwy are dong all work and then hoe outside conuaaars ttat1 submit a new afli i"s wdiw nW such. =Cosnraaors that diode this ban tarot atts I ao sMamml saner stwwnM the mow orthe sub-conancoms and sate whedw a tat those entities have employes. if the sub-conumo n bm ernplvyms tbey mm provide then workers•wnW.policy.anther. !am an enWoyer that is providing workers'compensation msurance for my entployeeL Below is the policy a»d job site infmmadex Insurance Company Name: Aa-464-tJ 67W Policy#or Self-ins.Lic.#: WO—/ /0 Q©C( Expiration Date: Job Site Address: So; 6466, a,-,— 40 cj— City/StateJZip: f( r#'CL-.'12�IA14 d to Go Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). F"wr to statue coverage as requited trader Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA far insurance coverage verification do hereby cen*5,r die pains nd penahies ojperjury Char the inforn"on prnvided above is tore and coned Si tune: s- Photo#• yl3 - q{)7-1N16 OjfscW use only. Do not wrist in this area,to be cvtgplered by city or town off dal City or Town: Permit/14cense Lssaing Authority(circle one): 1.Board of Health 7-Buikling Department 3.Citylfown Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ,... COMMONWEALTH OF MASSACHUSETTS MASSACHUSICTT� DRIVER'S • • • - - • • LICENSE BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE 4.ISS '.�:�ENO .d NUMBER W' *'o 10 NONE S19852961 AS A MASTER—UNRESTRICTED 015 10-14-197REST s SEX M i1;HGT 5.11 AARON S MOR I N DB N Z Uj CVI(7RiN 140 WEST ST AA 0 WEST ST n-'}ttor W HATFIELD,MA 01088.9500 HATFIELD MA 01088-9500 DO,U.,68U,aR.v07.,S2009 533 1 0/28/15 128908 � Entire House 1788 61513 35617 1630 1630 Other equip loads 0 0 Equip. @ 1.02 RSM 36329 Latent cooling 2173 TOTALS 1788 61513 38502 1630 1630 Printout certified by ACCA to meet all requirements of Manual J 8th Ed. wrightsoft Right-Suite@ Universal 7.1.16RSU02643 2014-May-0916:00:21 ,CCN Projectl.rup Calc=MJ8 Orientation=N Page 2 9 Load Short Form wri htsoft" Date: May 09,2014 Entire House By: john silk morin sheet metal 0M- a rmatlo al For: gleason road li - • • • Htg Clg Infiltration Outside db(°F) -5 97 Method Simplified Inside db (°F) 70 75 Construction quality Average Design TD(°F) 75 22 Fireplaces 0 Daily range - M Inside humidity(%) 30 50 Moisture difference (gr/lb) 30 43 HEATING EQUIPMENT COOLING EQUIPMENT Make Make Trade Trade Model Cond GAMA ID Coil ARI ref no. Efficiency 80 AFUE Efficiency 0 SEER Heating input 0 Btuh Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 OF Total cooling 0 Btuh Actual air flow 1630 cfm Actual air flow 1630 cfm Air flow factor 0.026 cfm/Btuh Air flow factor 0.046 cfm/Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0.94 ROOM NAME Area Htg load Clg load Htg AVF Clg AVF (ft2) (Btuh) (Btuh) (cfm) (cfm) pantry 99 3310 2321 88 106 kitchen 210 5857 6391 155 292 dinning room 169 5075 3407 134 156 living room 480 14299 7113 379 325 tv room 169 6634 3882 176 178 bed 1 132 4088 1768 108 81 master bed 240 5404 2215 143 101 office 289 16847 8520 446 390 Printout certified by ACCA to meet all requirements of Manual J 8th Ed. F~ +P— W right5oft- Right-Suite®Universal 7.1.16 ASU02643 2014-May-09 16:00:21 ACCA Projectl.rup Calc=MJ8 Orientation=N Page 1 INSURANCE COVERAGE: �,� I have a current liabilit�C insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes( No u If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy El� Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee rtnPC nnt have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waive 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 Tnsnectinns Date Final Tlcrerfinn Dates r nmmentc Type of License: By L✓J Master Title ❑ Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# � �-J � '�`� ❑Journeyperson-Restricted License Number: Fee$ El Check at www macs govt I Inspector Signature of Permit Approval r.. ID Commonwealth of Massachusetts JUN -2 2014 City Of Northampton Electric,Plumbing&Gas Ins ectl s Northamptcn. MA 01 It Sheet Metal Permit permit# Estimated Job Cost: $,/ ,©D Permit Fee: $ Plans Submitted: YES NO y Plans Reviewed: YES NO Business License# S � Applicant License# Business Information: Property Owner/Job Location Information: Name: _ _ ,y`��� Name: c' S (f lhat Street: NO blAesfshiee-17 Street: City/Town: City/Town: /�o r7�d% Telephone: �01 274W6 Telephone: Photo I.D. required/ Copy of Photo I.D. attached: YES ZNO Staff Initial J-1 // ylnrestricted 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 �ulti-family Condo/Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. o sq. ft. Number of Stories: r q g Sheet metal work to b ompleted: New Work: Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: Q (� /b( !� t - — �C- rsi 1 /l � /a✓� e i /6 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-2014-0060 APPLICANT/CONTACT PERSON AARON MORIN / ADDRESS/PHONE 140 WEST ST (413)247-05//50 PROPERTY LOCATION 50 GLEASON RD V ' MAP 18C PARCEL 090 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out Fee Paid Typeof Construction: CHANGE A/C UNIT IN MAIN HOUSE&ADDITION 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO 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 ermit from Elm Street Commission Permit DPW Storm Water Management Signature of Etulildirnjbf iciaf 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. 50 GLEASON RD SM-2014-0060 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON GIs#: 2197 Map: 18C Block: 090 __.-- SHEETMETAL PERMIT Lot: — 001 „..� Permit: SHEETMETAL Category: ADDITION Permit# SM-2014-0060 PERMISSION IS HEREBY GRANTED TO: Project# JS-2014-001071 Est.Cost: $13,800.00 Contractor: License: Expires: Fee Charged:$25.00 AARON MORIN Sheetmetal-533 10/28/2015 Balance Due:$:00 ' Owner: JOHNSON ALEXIS of Fixtures Applicant: AARON MORIN DigSafe# AT: 50 GLEASON RD UseGroup ConstClass I ISSUED ON. 03-Jun-2014 AMENDED ON. EXPIRES ON. TO PERFORM THE FOLLOWING WORK: CHANGE A/C UNIT IN MAIN HOUSE&ADDITION 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-2014-006924 02-Jun-14 1865 $25.00 212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck@northamptonma.gov GeoTMS®2014 Des Lauriers Municipal Solutions,Inc.