23B-046 (237) <: The Commonwealth of Massachusetts
Department of Industrial Accidents
w Office of Investigations
n 1 Congress Street, Suite 100
Boston MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lezibly
Name (Business/Organization/individual): NorthEastern Sheet Metal
Address:6 Niblick Rd.
City/State/Zip: Enfield, CT., 06082 Phone #:860-265-3805
Are you an employer? Check the appropriate box: Type of project(required):
1. ■❑ I am a employer with 32 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. F-1 New construction
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.❑ 1 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
employees. [No workers' 13.F-1 Other
comp. insurance required.]
*Any applicant that checks box 41 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:Arbella Indemnity
Policy#or Self-ins. Lic. #:9122570413 Expiration Date:4/15/15
Job Site Address: Cooley-Dickinson Hospital, 30 Locust St. City/State/Zip: Northampton, MA
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify nd a pains and penalties of perjury that the information provided above is true and correct.
Si nature: !/a/ 'G Date:12/10/2014
Phone#. 860- 5-3805
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
+ a
INSURANCE COVERAGE: �{
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yell No❑
If you have checked Yes,indicate the type of coverage by checking the appropriate box below:
A liability insurance policy X Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does nnf haves the insurance coverage required by Chapter 112 of the
Massachusetts General Laws,and that my signature on this permit application waive this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this box❑,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be
in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
Duct inspection required prior to insulation installation: YES NO
ProureSS fncnrtinnc
Date
Finest in enPrtinn
Dzte cummf-nts
Type of License:
By T Master 1113
Title ❑ Master-Restricted
Th a n,•g3 ASS ZA E
City/Town ❑Journeyperson
Signature of Licensee
Permit#
❑Journeyperson-Restricted License Number: �r 2223 Lbu 1-e--�-s SI
Fee$ X goj r .SS S19
Check at www mace gnv rinrl,
Inspector Signature of Permit Approval
Commonwealth of Massachusetts DEC 12 20i�
City Of Northampton
12 L0 �
Date: Sheet Metal Permit l � Permit# � —
� o�
Estimated Job Cost: $ Permit Fee: $ 50. D 9_i_ 996
Plans Submitted: YES x NO Plans Reviewed: YES NO
Business License# S- 11 Applicant License# 2-2- 2- 3
Business Information: Property Owner/Job Location Information:
,nn,,1- n
Name: Nfl('����S�QS r� ShQe� T`i•� Name: hoot¢/ 6*tLk,in59'1 lsd:iko�lCe.nAzr
Street: 6 Street: 30 "c_,SA -S7+-
City/Town: 'CT 06931- City/Town: N 0 r�krr. o�D4. WA
Telephone: 960- Us- 3 B OS Telephone: 4 13 - S$2 - 2doo
Photo I.D. required/Copy of Photo I.D. attached: YES v-' NO
Staff Initial
J-1 &nrestricted license
J-2 l 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. X Number of Stories:°°�
Sheet metal work to be completed: New Work: Renovation: X
HVAC Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney/Vents Air Balancing
Provide detailed description of work to be done:
A-_A-y 1 au(,#1,>o r K [6r- - ke- Co o l e
bra L r1
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, $100.00 Commercial
File#SM-2015-0021
APPLICANT/CONTACT PERSON NORTHEASTERN SHEET METAL CO INC
ADDRESS/PHONE 32 LAWNACRE RD (860)292-6883
PROPERTY LOCATION 30 LOCUST ST-CANCER CENTER
MAP 23B PARCEL 046 001 ZONE M(99)/WP(21)/URB(l)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
of-
Fee Paid
Typeof Construction: SHEETMETAL DUCTWORK FOR CANCER CTR ADDITION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 2223
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER: §
Intermediate Project: Site Plan AND/OR Special Permit with Site Plan
Major Project: Site Plan AND/OR Special Permit with Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
i om Elm Street Commission Permit DPW Storm Water Management
r
Sii riature 6'f Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact the Office of
Planning&Development for more information.
------ -----------
30 LOCUST ST - CANCER CENTER SM-2015-0021
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
PIS#: 909$ _
Map: 23B
Block: ° 6
Lot: \• SHEETMETAL PERMIT
001 ,,
Permit: SHEETMETAL ` 'IIIII . Ri IPA
Category: SHEETMETAL
Permit# SM-2015-0021 _ PERMISSION IS HEREBY GRANTED TO:
Project# 7S-2015-000753
Est.Cost: Contractor: License: Expires:
Fee Charged:$50.00 NORTHEASTERN SHEET METAL Sheetmetal-2223 08/28/2015
Balance Due:$.00 Owner: COOLEY DICKINSON HOSPITAL INC
#of Fixtures Applicant. NORTHEASTERN SHEET METAL CO INC
DigSafe# AT. 30 LOCUST ST-CANCER CENTER
UseGroup
ConstClass
ISSUED ON.• 15-Dec-2014 AMENDED ON.• EXPIRES ON:
TO PERFORM THE FOLLOWING WORK:
SHEETMETAL DUCTWORK FOR CANCER CTR 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-2015-002429 12-Dec-14 28802 $50.00
212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck @northamptonma.gov
GeoTMS®2014 Des Lauriers Municipal Solutions,Inc.