31A-226 (2) The Commonwealth of Massachusetts
Department of Industrial Accidents
w
Office of Investigations
o I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): I � V C __--.O ^.
Address: 3�) OV-000 On,V�2
City/State/Zip: Phone #: �
Aou an employer? Chec t�ppropriate box: Type of project(required):
1.FI am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-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 g, ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ 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.[ � / , /
j] ther F—t" V
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: � ��t � f i�� � � 00.
Policy#or Self-ins. Lic. #: W f '7`f q q Expiration Date: C�A zA Q
Job Site Address: —I 3, 140 r(I s«I ) n Ve City/State/Zip:
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce y under the pai andpenalties ofperjury that the information provided above is true and correct.
Signature: Dat e:
Phone#:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
INSURANCE COVERAGE: ��
I have a current liabilitK insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes[ , No❑
If you have checked Yes,indicate the type of coverage by checking the appropriate box below:
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee dnPg not hay P the insurance coverage required by Chapter 112 of the
Massachusetts General Laws,and that my signature on this permit application waive this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this box❑,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be
in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
Duct inspection required prior to insulation installation: YES NO
ProarPcc 1ncpeCtinnc
.Date Lomment&
Final incpvrtinn
Date
Type of License:
By 01"Master
Title ❑ Master-Restricted , mac
City/Town ❑Journeyperson
Signature of Licensee
Permit#
❑Journeyperson-Restricted 6_3 a
License Number:
Fee$ ❑
Check at www macs Clnvldpi
Inspector Signature of Permit Approval
I SEP - 2 2014 i Commonwealth of Massachusetts
[ _ City Of Northampton
Electric, Plurnbing&Gas inspections
�,orthar-=`°n' Mir, Sheet Metal Permit Permit# 50 — /Y-7
Date:
Estimated Job Cost: $ Permit Fee: $ 0�'
Plans Submitted: YES NO Plans Reviewed: YES NO
Business License# Q3 Applicant License# 9 OV57
Business Information: Property Owner/Job Location Information:Name: I ��J�� �V ?-t� Name:
+
de
Street: A 0 I r � ��(� �,4treet: qa Ho r r/ S t�Ve,
City/Town: Y esf_ "( e I d t�I 0 V '''1JJJ�lCity/Town: 0
Telephone: ( (4 6) NA 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 V Multi-family Condo/Townhouses Other
Commercial: Office Retail Industrial Educational
Institutional Other
Square Footage: under 10,000 sq. ft. t�al over 10,000 sq. ft. Number of Stories:
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:
CZ C� C CX�I
cc
Fees with Building Permit:$25.00 Residential, $50.00 Comme_r,�l.Fees for jobs without a Building Permit$6.00 per$1000
Minimum fees for jobs without Bu�ingTermlt$50.00 Residential,$100.00 Commercial
File#SM-2015-0007
APPLICANT/CONTACT PERSON A PLUS HVAC INC
ADDRESS/PHONE 26 AIRPORT DR (413)562-0054
PROPERTY LOCATION 42 HARRISON AVE
MAP 31A PARCEL 226 001 ZONE URI3000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: FURNACE CHANGE OUT
New Construction
Non Structural interior renovations
Addition to Existiniz
Accessory Structure _
Building Plans Included:
Owner/Statement or License 103
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOI MATION 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
Pmnit from Elm Street Commission Permit DPW Storm Water Management
Signs ure o'rBdffdin7g dfficirl 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.
42 HARRISON AVE SM-2015-0007
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
IGIS#: 5834
[Map: 31A
SHEETMETAL PERMIT
Block: 226
k Lot: 001
ennit:_ SHEETMETAL
iCategory: SHEETMETAL
Permit#, SM-2015-0007 PERMISSION IS HEREBY GRANTED TO:
(Project# JS-2015-000080
-
[Est Cost: Contractor: License: Expires:
Fee Charged:$5Q 00 A PLUS HVAC INC Sheetmetal- 103 11/08/2014
jBalance Due:$.00 Owner: WILSON ROBERT H&LINDA E SOPP CO-TRUSTEES
#of Fixtures Applicant: A PLUS HVAC INC
DigSafe#_ _ AT: 42 HARRISON AVE
UseGroup _
ConstClass
ISSUED ON: 05-Sep-2014 AMENDED ON: EXPIRES ON.
TO PERFORM THE FOLLOWING WORK:
FURNACE CHANGE OUT
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-2015-000983 03-Sep-14 8225 $50.00
212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck @northamptonma.gov
GeoTMSO 2014 Des Lauriers Municipal Solutions,Inc.