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24C-159 (3) DIMENSIONS - INCHES C 20-3/8" (Opening) (Opening) A Y l � 21-1/2" B BOTTOM OPENING DIMENSIONS p" 20-1/4" Dimensions-FC Upflow/Downflow Full Cased Coils Dimensions 1 Refrigerant Connections 2 Models Height Width Opening Widths Line Size A B C D Liquid Vapor FC18A 18 14-1/2 13-3/8 13-1/2 FC18B 18 17-1/2 16-3/8 16-1/2 FC24A 22 14-1/2 13-3/8 13-1/2 FC24B 22 17-1/2 16-3/8 16-1/2 FC30A 22 14-1/2 13-3/8 13-1/2 3/4 FC30B 22 17-1/2 16-3/8 16-1/2 FC32A 20 14-1/2 13-3/8 13-1/2 FC35B 20 17-1/2 16-3/8 16-1/2 FC35C 20 21 19-7/8 20 FC36A 24-1/2 14-1/2 13-3/8 13-1/2 FC36B 24-1/2 17-1/2 16-3/8 16-1/2 7/8 FC36C 24-1/2 21 19-7/8 20 3/8 FC37A 24-1/2 14-1/2 13-3/8 13-1/2 3/4 FC42B 28 17-1/2 16-3/8 16-1/2 FC42C 28 21 19-7/8 20 FC43B 24-1/2 17-1/2 16-3/8 16-1/2 FC43C 24-1/2 21 19-7/8 20 FC48C 28 21 19-7/8 20 7/8 FC48D 28 24-1/2 23-318 23-1/2 FC60C 28 21 19-718 20 FC60D 28 24-1/2 23-3/8 23-1/2 FC62D 32 24-1/2 23-3/8 23-1/2 FC64D 36 24-1/2 23-3/8 23-1/2 1. All dimensions are in inches. 2. Refrigerant line sizes may require larger lines for extended line lengths.See Application Data part number 247077. Subject to change without notice.Published in U.S.A. 813519-USD-B-0813 Copyright©2013 by Johnson Controls,Inc.All rights reserved. Supersedes:813519-USD-A-1012 York International Corp. 5005 York Drive Norman,OK 73069 700706-YTG-E-0913 LEFT SIDE FRONT RIGHT SIDE Combustion Air Inlet Combustion Air Inlet Condensate Drain Gas Pipe (Downflow) Entry Gas Pipe Condensate Drain Entry or(Downflow) Vent Outlet— ►O Electrical Electrical CD Entry Entry Vent Outlet Condensate Drain ® ® 33 Condensate 23" I r m ®Thermostat Drain �I Wiring o r Thermostat @I Wiring Optional Return Air Cutout(Either side) 14° �f 28.5" —►�I �—A 1.5" �{ I .56 �— 23.8" 10 3" ---- — Vent T Outlet T B Combustion B Air Inlet C .56',_t 56" , If 24.25" i) 20„ SUPPLY END RETURN END Cabinet&Duct Dimensions Model Nominal Cabinet Cabinet Dimensions(Inches) Approximate Operating Weights CFM(m3/min) Size A B C Lbs TM9V040A10MP11C 1000 A 14-1/2 13-3/8 11-3/4 113 TM9V060B12MP11C 1200 B 17-1/2 16-3/8 13-1/4 122 TM9V080B12MP11C 1200 B 17-1/2 16-3/8 13-1/4 126 TM9V080C16MP11C 1600 C 21 19-7/8 16-1/2 136 TM9V100C16MP11C 1600 C 21 19-7/8 18-1/4 142 TM9V100C20MP11C 2000 C 21 19-7/8 18-1/4 145 TM9V120D20MP11C 2000 D 24-1/2 23-3/8 21-3/4 156 Ratings&Physical/Electrical Data Input Output Total AFUE High Fire Low Fire Model High/Low High/Low Unit Air Temp.Rise Air Temp.Rise MBH MBH Amps % °F °F TM9V040A10MP11C 40/26 38/25 9 96 30-60 20-50 TM9V060B12MP11C 60/39 58/37 9 96 35-65 35-65 TM9V080B12MP11C 80/52 77/50 9 96 40-70 35-65 TM9V080C16MP11C 80/52 77/50 12 96 35-65 35-65 TM9V100C16MP11C 100/65 96/62 12 96 35-65 30-65 TM9V100C20MP11C 100/65 96/62 14 96 35-65 35-65 TM9V120D20MP11C 120178 115/75 14 96 35-65 35-65 Max.Outlet Blower Blower Size Max. Min.Wire Size Model Air Temp. Over-current (awg)@ 75 ft. °F HP Amps In. Protect One Way TM9V040A10MP11C 180 1/2 7 11 X8 15 14 TM9V060B12MP11C 180 1/2 7 11 x8 15 14 TM9V080B12MP11C 175 1/2 7 11 x8 15 14 TM9V080C16MP11C 165 3/4 10.2 11 x 10 15 14 TM9V100C16MP11C 180 3/4 10.2 11 x 10 15 14 TM9V100C20MP11C 170 1 12.7 11 x 11 20 1 12 TM9V120D20MP11C 180 1 123 11 x 11 20 12 Annual Fuel Utilization Efficiency(AFUE)numbers are determined in accordance with DOE Test procedures. Wire size and over current protection must comply with the National Electrical Code(NFPA-704atest edition)and all local codes. The furnace shall be installed so that the electrical components are protected from water. 2 Johnson Controls Unitary Products q V0 dn G l �f/� e 11 700706-YTG-E-0913 DESCRIPTION w These compact units employ induced combustion, reliable hot WMYOR surface ignition and high heat transfer aluminized tubular heat exchangers. The units are factory shipped for installation in upflow or horizontal applications and may be converted for downflow applications. Heating and Air Conditioning These furnaces are designed for residential installation in a basement, closet, alcove, attic, recreation room or garage and TECHNICAL GUIDE are also ideal for commercial applications. All units are factory assembled, wired and tested to assure safe dependable and 96% AFUE TWO STAGE VARIABLE SPEED ECM economical installation and operation. RESIDENTIAL GAS FURNACES These units are Category IV listed and may be vented either MULTI-POSITION through side wall or roof applications using approved plastic combustion air and vent piping. MODELS: TM9V*C FEATURES NATURAL GAS 40-120 MBH INPUT Two stage heating operation includes two stage gas valve, two stage inducer operation and variable speed ECM blower operation.Adjustable delay timer allows two stage operation with a single stage thermostat. • Easily applied in upflow,horizontal left or right,or downflow ` installation with minimal conversion necessary. Compact,easy to install,ideal height 33"tall cabinet. ` ECM variable speed drive for cooling SEER enhancement, g improved comfort with optional airflow delay profiles,and x r continuous fan options for IAQ performance. fl; Easy access to controls to connect power/control wiring. Built-in,high level self diagnostics with fault code display. ? s Low unit amp requirement for easy replacement application. • All models are convertible to use propane(LP)gas. Electronic Hot Surface Ignition saves fuel cost with increased dependability and reliability. tF • 100%shut off main gas valve for extra safety. • 24V,40 VA control transformer and blower relay supplied for add-on cooling. • Hi-tech tubular aluminized steel primary heat exchanger with stainless steel tube/aluminum fin secondary heat exchanger for outstanding efficiency. Goad llaaelceepn►g --- „ n %$air Solid removable bottom panel allows easy conversion. • Airflow leakage less than 1%of nominal airflow for duct DOE 1 GFR P.,1 430 blaster conditions. • No knockouts to deal with,making installation easier. Movable duct connector flanges for application flexibility. 9060REGtSGO Quiet inducer operation,burner,and blower operation. ISO 9001 Certified Quality Inducer rotates for easy conversion of venting options. Management System Due to continuous product improvement,specifications are Fully supported blower assembly for easy access and subject to change without notice. removal of blower. Visit subject to the web it out notice. External air filters used for maximum flexibility in meeting customers IAQ needs. Additional rating information can be found at Insulated blower compartment for thermal and acoustic per- www.ahridirectory.orct formance. WARRANTY SUMMARY 1/4 turn knobs provided for easy independent door removal. A 20-year limited warranty on heat exchangers in residen- Internal condensate trap design(patent pending)provides tial applications. condensate management options and is self priming to pre- A 10-year warranty on the heat exchanger in commercial vent nuisance problems. applications. Protection included from air intake,exhaust vent or conden- Standard 5-year limited Parts warranty. sate blockage. Extended lifetime heat exchanger and 10-year limited Venting applications maybe installed as either 2 pipe sealed parts warranty when product is registered online within combustion or single pipe vent using indoor combustion air. 90 days of purchase for replacement or closing for new These models may be connected as part of a home construction. communicating control system using a 4-wire connection See Limited Warranty certificate in Users Information Manual for details. bus. FOR DISTRIBUTION USE ONLY NOT TO BE USED AT POINT OF RETAIL SALE 1109217-YTG-A-0714 COOLING CAPACITY-With High Efficiency Motor Furnaces(Continued) FURNACE COOLING UNIT COIL NET MBH MODEL MODEL WIDTH MODEL' STAGE RATED SEER EER CFM TOTAL SENS. 18 SEER AC WITH HIGH EFFICIENCY MOTOR FURNACES2 Y*9C*B12 17.5 HD36 1 590 20.2 13.2 17.25 22.00 2 815 22.8 15.5 13.50 Y*9C*C16 21.0 FC/MC/PC35C 1 645 21.2 14.5 17 75 23.25 2 900 23.4 17.1 13.50 Y*9C*C16 21.0 FC/MC/PC48C 1 635 21.4 14.5 18.25 24.00 2 890 23.8 17.5 14.00 CZH02412C Y*9C*C16 21.0 UC48C 1 635 21.0 14.4 17.50 23.25 2 890 23.4 17.2 13.75 Y*9C*C20 21.0 FC/MC/PC43C 1 630 21.2 14.5 18.00 23.75 2 890 23.8 17.4 14.00 Y*9C*C20 21.0 FC/MC/PC48C 1 630 21.4 14.5 18.25 24.00 2 890 23.8 17.5 14.00 Y*9C*C20 21.0 UC48C 1 630 21.0 14.2 23.25 2 890 23.4 17.2 17.50 13.75 T*(8,L)V*Al2 14.5 FC/MC/PC37A 1 730 28.8 18.5 16.75 21.50 2 1150 34.4 23.6 12.75 T*(8,L)V*B12 17.5 FC/MC/PC35B 1 775 28.8 18.7 16.75 21.75 2 1150 34.2 23.6 12.75 T*(8,L)V*B12 17.5 FC/MC/PC43B 1 860 29.8 20.1 17.00 22.00 2 1275 35.0 24.8 12.50 T*(8,L)V*B12 17.5 HD48 1 750 29.2 18.8 17.50 22.75 2 1210 35.4 24.4 13.25 T*(8,L)V*C16 21.0 FC/MC/PC35C 1 770 29.0 18.8 17 00 22.00 2 1210 34.4 23.8 13.00 T*(8,L)V*C16 21.0 FC/MC/PC43C 1 770 29.2 19.1 17.25 22.50 2 1190 35.0 24.4 13.50 T*(8,L)V*C16 21.0 FC/MC/PC48C 1 725 29'2 18'7 17.25 22.50 2 1195 35.4 24.6 13.75 1 710 29'2 18.8 22.50 T*(8,L)V*C16 21.0 FC/PC60C 17 25 2 1185 35.0 24.0 13.75 1 810 29.8 19.5 23.25 T*(8,L)V*C16 21.0 HD48 2 1210 35.8 24.6 18.00 13.75 CZH03612C T*(8,L)V*C16 21.0 UC48C 1 810 28.8 19.1 17.00 22.25 2 1210 34.8 24.0 13.50 T*(8,L)V*C16 21.0 UC60C 1 810 29.4 19.3 17.50 23.00 2 1195 35.0 24.4 13.50 T*(8,L)V*C20 21.0 FC/MC/PC35C 1 1020 30.2 21.3 1 17.25 22.50 2 1165 34.2 23.6 13.00 T'(8,L)V*C20 21.0 FC/MC/PC43C 1 740 29.0 18.8 17.25 22.50 2 1190 35.0 24.4 13.50 1 T*(8,L)V*C20 21.0 FC/MC/PC48C 17.50 2 11155 0 35.2 24.2 29.0 18.6 22.75 13.75 T*(8,L)V*C20 21.0 FC/PC60C 1 800 29.6 19.5 17.75 23.25 2 1215 35.4 24.8 13.75 T*(8,L)V*C20 21.0 HD48 1 720 29.0 18.5 17.75 23.00 2 1155 35.4 24.2 13.75 T*(8,L)V*C20 21.0 UC48C 1 720 28.0 18.2 16.75 21.75 2 1155 34.0 23.2 13.25 T*(8,L)V*C20 21.0 UC60C 1 800 29.4 19.3 17.50 23.00 2 1215 35.0 24.4 13.50 1 810 28.8 18.7 16.50 21.50 T*9V*B12 17.5 FC/MC/PC35B 2 1190 34.2 23.6 12.50 For Notes See Page 28. Johnson Controls Unitary Products 9 1109217-YTG-A-0714 ® DESCRIPTION iJYORK The 18 SEER Series unit is the outdoor part of a versatile cli- mate system. It is designed with a matching indoor coil compo- nent from. Available for typical applications this climate system is supported with accessories and documents to serve specific functions. FEATURES Superior Coil Protection -A stamped, decorative metal coil TECHNICAL GUIDE guard protects the tube-in-fin coil from debris and other damag- ing material. AFFINITYTM SERIES Protected Compressor - The compressor is safeguarded SPLIT SYSTEM AIR CONDITIONERS against abnormal pressures and temperatures by an internal pressure relief valve, an internal temperature sensor, and fac- 18 SEER— R-41 OA— 1 PHASE tory high and low pressure system controls. A factory installed liquid line filter-drier further protects the compressor against 2 THRU 5 NOMINAL TONS moisture and debris. MODELS: CZH024 THRU 060* Environmentally Friendly Refrigerant - The next generation refrigerant R-410A delivers environmentally friendly perfor- mance with zero ozone depletion. Durable Finish-An automotive quality finish provides the ulti- mate protection from harmful UV rays and rust creep, ensuring . a long-lasting,high quality appearance. A powder-paint topcoat is applied over a baked-on primer using a galvanized, zinc coated steel base material. The result is a finish that has been proven in testing to provide 33%greater durability than conven- tional powder-coat finishes. QuietDriveTM System - Features combination of swept-wing fan, composite base pan, isolated compressor compartment, and two-stage compressor to reduce overall sound to a mere whisper. Low RPM ECM Fan Motor-Helps to reduce airflow noise. Swept Wing Fan -A fan design boasting technology adapted from aeronautic and defense engineering provides for whisper- quiet operation by allowing air to flow smoothly and efficiently across the fan tips. Composite Base Pan - The strong and durable composite ,,ow�a^°*°°°M°•F°. base pan provides added strength while resisting rust and cor- GmalHouselceeping rosion,as well as reducing sound and vibration. °Fq�PrtfOr11138S�EC,( Isolated Compressor Compartment - A molded composite H 11 bulkhead isolates the refrigeration components and the com- AMERICAN r' —" pressor from the rest of the unit, reducing sound and vibration. QUALITY tj j Lower Installed Cost - Designed to provide enhanced instal- DESIGNED,ENGINEERED& ® <` ____/,; lability by featuring a slide-down control compartment that ASSEMBLED IN THE USA j I��h+n h1y,1.tR�� 1509001 allows easy access to control components, along with angled P C US 4` service valves to reduce overall installation time and cost. Fac- Certified Quality Management System tory charged for a 15 foot lineset. Due to continuous product improvement,specifications Factory Installed Filter-Drier - A factory installed, solid core are subject to change without notice. liquid line filter-drier removes harmful debris and moisture from the system. Visit us on the web at Easy Service Access - A full end, full service access panel www.upgnet.com and www.york.com with handle makes for easy entry to internal components. Additional rating information can be found at Communications Capable - Requiring only a simple 4-wire www.ahridirectory.orp installation,the communicating capability enables the use of the Touch Screen Communicating Control,allowing real time visibil- WARRANTY SUMMARY* ity of system operation and the use of diagnostic features,while Extended 10-Years limited parts warranty. still maintaining the ability to function with a traditional thermo- Extended Lifetime limited compressor warranty. stat. Extended parts and compressor warranties require online reg- Premium System Warranty* - Limited lifetime compressor istration within 90 days of purchase for replacement or closing for warranty when registered online within 90 days of installation. new home construction. Agency Listed - Safety certified by CSA to UL 1995 / CSA 22.2. Performance certified to ANSI/AHRI Standard 210/240 in *Does not apply to R-22 models,3-Phase models,or internet sales. accordance with the Unitary Small Equipment certification pro- See Limited Warranty certificate in User's Information Manual for details. gram. FOR DISTRIBUTION USE ONLY-NOT TO BE USED AT POINT OF RETAIL SALE 1Nt'I 9 htSQft` Load Short Form Job: Date: Dec 24,2014 2ND FLOOR By: J.SZUMSKI AARON MORIN Project • • For: HYMAN NORTHAMPTON, MA Design Information Htg Clg Infiltration Outside db (°F) 0 87 Method Simplified Inside db(°F) 75 70 Construction quality Semi-loose Design TD(°F) 75 17 Fireplaces 0 Daily range - M Inside humidity(%) 50 50 Moisture difference(gr/lb) 61 34 HEATING EQUIPMENT COOLING EQUIPMENT Make n/a Make n/a Trade n/a Trade n/a Model n/a Cond n/a AHRI ref n/a Coil n/a AHRI ref n/a Efficiency n/a Efficiency n/a Heating input Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 °F Total cooling 0 Btuh Actual air flow 0 cfm Actual air flow 0 cfm Air flow factor 0 cfm/Btuh Air flow factor 0 cfm/Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat n/a Load sensible heat ratio 0 ROOM NAME Area Htg load Clg load Htg AVF Clg AVF (ftz) (Btuh) (Btuh) (cfm) (cfm) BED 1 144 3758 2049 130 124 BED2 144 2400 1780 83 108 BED3 152 2682 1409 93 85 CLO 1 24 838 149 29 9 BATH2 64 1635 922 56 56 LAUNDRY 45 474 550 16 33 BATH 3 36 1429 869 49 53 2ND FLOOR 609 13216 7728 456 467 Other equip loads 0 0 Equip. @ 0.92 RSM 7109 Latent cooling 645 TOTALS i 609 I 13216 i 7754 i 456 l 467 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. 2014-Dec-24 12:28:04 ,.. wrlghtsoft Right-Su ite®U niversal 2012 12.1.05 RSU18115 Page 3 C:\Users\andrey.yurovski\Desktop\WRITE SOFT JOBS\AARON-HYMAN.rup Calc=MA Front Door faces: wry El $CI 9 Load Short Form Jab. Date: Dec 24,2014 1ST FLOOR By: J.SZUMSKI AARON MORIN Project Information For: HYMAN NORTHAMPTON, MA Design Information Htg Clg Infiltration Outside db(°F) 0 87 Method Simplified Inside db(°F) 75 70 Construction quality Semi-loose Design TD(°F) 75 17 Fireplaces 0 Daily range - M Inside humidity(%) 50 50 Moisture difference(gr/lb) 61 34 HEATING EQUIPMENT COOLING EQUIPMENT Make n/a Make n/a Trade n/a Trade n/a Model n/a Cond n/a AHRI ref n/a Coil n/a AHRI ref n/a Efficiency n/a Efficiency n/a Heating input Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 OF Total cooling 0 Btuh Actual air flow 0 cfm Actual air flow 0 cfm Air flow factor 0 cfm/Btuh Air flow factor 0 cfm/Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat n/a Load sensible heat ratio 0 ROOM NAME Area Htg load Clg load Htg AVF Clg AVF (ft2) (Btuh) (Btuh) (cfm) (cfm) TV ROOM 192 4963 3510 171 212 ENTRY 60 1588 401 55 24 LIVING 351 6074 3668 210 222 ENTRY 2 78 2002 422 69 26 HALL 166 3438 2183 119 132 1/2 BTH 30 1174 1023 40 62 KITCHEN 220 4453 4371 154 264 1ST FLOOR 1097 23693 15577 817 942 Other equip loads 0 0 Equip. @ 0.92 RSM 14331 Latent cooling 991 TOTALS 1097 I 23693 15322 I 817 I 942 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. 2014-Dec-24 12:28:04 �+- wrlghtsoft' Rig ht-Su ite®Universal201212.1.05RSU18115 Paget C:\Users\andrey.yurovski\Desktop\WRITE SOFT JOBSWARON-HYMAN.rup Calc=MA Front Door faces: 111/1"1 9 ht$Q Load Short Form Job. Date: Dec 24,2014 Entire House By: J.SZUMSKI AARON MORIN Project Information For: HYMAN NORTHAMPTON, MA Design Information Htg Cig Infiltration Outside db(°F' 0 87 Method Simplified Inside db(°F) 75 70 Construction quality Semi-loose Design TD(°F) 75 17 Fireplaces 0 Daily range - M Inside humidity(%) 50 50 Moisture difference(gr/lb) 61 34 HEATING EQUIPMENT COOLING EQUIPMENT Make Make Trade Trade Model Cond AHRI ref Coil AHRI ref Efficiency 80 AFUE Efficiency 0 SEER Heating input 0 MBtuh Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 °F Total cooling 0 Btuh Actual air flow 1273 cfm Actual air flow 1273 cfm Air flow factor 0.035 cfm/Btuh Air flow factor 0.060 cfm/Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0.93 ROOM NAME Area Htg load Clg load Htg AVF Cig AVF (ft2) (Btuh) (Btuh) (cfm) (cfm) 1ST FLOOR 1097 23693 15577 817 942 2ND FLOOR 609 13216 7728 456 467 Entire House 1706 36909 20868 1273 1273 Other equip loads 0 0 Equip. @ 0.92 RSM 19199 Latent cooling 1636 TOTALS i 1706 I 36909 i 20835 I 1273 I 1273 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. 2014-Dec-24 12:28:04 wrightsoft Right-Suite®universal 2012 12.1.05 RSU18115 Page 1 k C:\Users\andrey.yurovski\Desktop\WRITE SOFT JOBS\AARON-HYMAN.rup Calc=MJ8 Front Door faces: 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 hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an 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 state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." 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 necessary, supply sub-contractor(s)name(s), address(es)and phone number(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. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. 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-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The 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 fill in the permit/license 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 on 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext 7406 or 1-877-MASSAFE Revised 7-2013 Fax#617-727-7749 www.mass.gov/dia The Commonwealth of Massachusetts Department of IndustrialA ccidents Office of Investigations 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): Address: City/State/Zip 1✓ �� � �� cyo ge Phone#: Are yo,wan employer?Check the appropriate box: Type of project(required): 1. I am a employer with 9 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]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' [No workers' comp.insurance comp. insurance. $ 9. E]Building addition 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' D.P'6ther/lP-JSPf�-S k-S�e•-'� comp. insurance required.] f 1� - ✓a�� *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. r Insurance Company Name: Policy#or Self-ins. Lic.#: 6�e �� 90 Expiration Date: Job Site Address: (70- -f- ity/State/Zip: o✓' '% oloC-o 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify d r the pains and enalties ofperjury that the information provided above is true and correct Si tore: /�/ Date: ��4 Phone#: q('3—�a 7 r ` W 6 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: INSURANCE COVERAGE: �� I have a current liahilit�v insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes u No❑ If you have checked Yes,indicate the ty of coverage by checking the appropriate box below: A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does nn+have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waive this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑,1 hereby certify that all of the details and information 1 have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO Progress Inspections Date Comments ,FiUal Tnsperfinrn Date Cmmmmnts Ty�aster ense: BY Title ❑Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# -# S ❑Journeyperson-Restricted License Number: Fee$ F1 Check at-macs gnv_,/rinl Inspector Signature of Permit Approval .; DEC 2 9 2014 !J Commonwealth of Massachusetts City Of Northampton Date o'�21_ Sheet Metal Permit permit# Sm Estimated Job Cost: $ o , 6 00.00 Permit Fee: $J' r Plans Submitted: YES NOt� Plans Reviewed: YES NO Business License# 14 53 3 Applicant License# Business Information: __ Property Owner/Job Location Information: � Name: 45- /rco�y� `Lwfr� - � Name: AA6n- lei O/K CA-V",- Street: qo,./e St Street: City/Town: 1,le f-- City/Town: /7od- /�- Telephone: q13-y,97—/V/6 V Telephone: 5-E y ,3-7 Photo I.D. required/Copy of Photo I.D. attached: YES (/ NO Staff Initial J-1 Oestricted 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. Zover 10,000 sq. ft. Number of Stories: o�? 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: 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-2015-0024 APPLICANT/CONTACT PERSON AARON MORIN ADDRESS/PHONE 140 WEST ST (413)247-0550 Q PROPERTY LOCATION 22 ARLINGTON ST MAP 24C PARCEL 159 001 ZONE URB000)/ 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: INSTALL NEW SPLIT SYS W/NEW 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO TION 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 in Street Comm' ion Permit DPW Storm Water Management Signature of Building 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. 22 ARLINGTON ST SM-2015-0024 COMMONWEALTH OF MASSACHUSETTS _ CITY OF NORTHAMPTON IG #: 3834 ,,Map: 24C dock: 159 - . , SHEETMETAL PERMIT =Lot. —6-01 _ _ „�.,• Permit; SHEETMETAL Category: SHEETMETAL `Permit# SM-201_5-0024 i PERMISSION IS HEREBY GRANTED TO: -Project.# JS-2015-000783il IEst.Cost: $22,600._0_0 Contractor: License: Expires: Fee Charged:$25.00 AARON MORIN Sheetmetal-533 10/28/2015 :Balance Due:$.00 Owner: HYMAN SHERRY B&ARTHUR �#of Fixtures _ Applicant: AARON MORIN DigSafe# AT: 22 ARLINGTON ST UseGroup &IIStC1aSS ISSUED ON: 30-Dec-2014 AMENDED ON: EXPIRES ON. TO PERFORM THE FOLLOWING WORK: INSTALL NEW SPLIT SYS W/NEW 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-2015-002609 30-Dec-14 2101 $25.00 212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck @northamptonma.gov GeoTMS®2014 Des Lauriers Municipal Solutions,Inc.