16D-004 (4) In IA � Q DRAWINGS PROVIDED BY: PROJECT LOCATION SHEETTTI7_E: NO. DESCRIPTION BY DATE
M > 4 Joslad & Associates, P.C. 206 N. Main Street
(� FP o 83 Superior Avenue Northampton, MA FIRST FLOOR PLAN
uI Indian Orchard, MA 01151
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M A m 7oslad &Associates, P.C. 206 N. Main Street
LA) +
!-q 83 83 Superior Avenue SECOND FLOOR PLAN
Indian Orchard, MA 01151 Northampton, MA
<COMMONWE ►LTH OF MASAHUSETTS
• • • - • •
B:oA�n'o
SHEET':METAL WORKERS
ISSUS .THE FOLLOWING LICENSE
AS"A MASTER UNRESTRICTED
iZ
8R 1 AN W TATRO ,. _.
4 BERARO C I'R W
SPR I NGF,l L.0 MA 01128-1.
,-004
1 1' 0 T 2 >28/16> 48546
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MASSACHUSETTS' DRIVER'S
"LICENSE==---V5A
Z1{OF
.0?Cj,9�END 4d NUMBER-'
s�NONE 566442565
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15 SEX Im;` 1 ''
9 41 DARBY DR _
WESTFIELD,MA'01085.4705
5 DD 12-27-2012 Rev 07.15-2009 -
Imormation, 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-contractors)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 406 or 1-877-MASSAFE
Revised 7-2010 Fax# 617-727-7749
www.mass.gov/dia
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
1 Congress Street,Suite 100
�+ Boston,MA 02114-2017
www.tnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Coo;:tractors/Electriciaas/Plumbers
Applicant Information Please Print L,e�zibly
Name (Business/Organization/Individual): �r rt� c= I rz,
Address: 1-(" 13 C/
City/State/Zip: s C/ trn el v C�a kPhone#: �=( ��- G C -SAS` q O
Are you an employer? Check the appropriate boa: Type of project(required):
1.-Q I am a employer with 4, 4. EJ I am a general contractor and I
employees (full and/or part-time).* have hued the sub-contractors 6. -{ 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 & Demolition
working for me in any capacity. employees and have workers'
insurance.$ 9. ❑Building addition
[No workers coin comp. insurance P•
required.] 5. F—] We are a corporation and its 10.0 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 12.0 Roof repairs
insurance required.] c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
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 attache]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 tliat isproviding workers'compensation insurance for nay employees. Below is thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 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 certify under he pains and penalties of perjury that the information provided above is true and correct
anaur it r -�Si
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#:
File#SM-2015-0043
APPLICANT/CONTACT PERSON BRIAN TATRO
ADDRESS/PHONE 4 BERARD CIR (413)782-2290 Q
PROPERTY LOCATION 206 NORTH MAIN ST-LOT 2
MAP 16D PARCEL 004 001 ZONE URB(75)/URA(25)/
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: SHEETMETAL FOR NEW SFH
New Construction
Non Structural interior renovations
Addition to Existing-
Accessory Structure
Building-Plans Included:
Owner/Statement or License 11990
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOjPvIATION 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
it Street Co 'ssicn Permit DPW Storm Water Management
Sig a ure(;TBU`ffd_i4 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.
INSURANCE COVERAGE:
have a current liabilit insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yeses.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 arPz not harp 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 19 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 Tnsnertinns
Date �
Final inc�eCtinn
Date �
Type of License:
By ❑ Master
Title ❑ Master-Restricted
City/Town ❑Journeyperson
Signature of Licensee
Permit#
❑Journeyperson-Restricted License Number:
Fee$ ❑
Check at S mal macs gnvlrfpl
Inspector Signature of Permit Approval
�L- Commonwealth of Massachusetts
K 2 2 201 City Of Northampton
Electric. Sheet Metal Permit
5
No Permit# S
Estimated Job Cost: $ ��6)C c J Permit Fee: $
Plans Submitted: YES -'` -NO Plans Reviewed: YES NO
Business License# Applicant License# / / -1 Q
Business Inform ation: Property Owner/Job Location Information:
Name: 4- C' t`y Name: ) 5 'C� S-so C PS
Street: f /�c-CCA r 0 C r Street:
City/Town: City/Town: o.)t �.c <'-
Telephone: I j - S �5_S_61 D Telephone: LI Ll 4-(
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
Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. Number of Stories:
Sheet metal work to be completed: New Work: v Renovation:
HVAC Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney/Vents Air Balancing
Provide detailed description of work to be done:
SyS � �
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
206 NORTH MAIN ST - LOT 2 SM-2015-0043
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
GIS#: 1281
Map:_ 16D
Block: 004 -- : , SHEETMETAL PERMIT
i%ot 001
Permit: SHEETMETAL_
Category:
Pertnit# SM-2015-0043 PERMISSION IS HEREB Y GRANTED TO:
Project# JS-2_015-001717
-Contractor: License: Expires:
Est Cost: $1.0,000.00 P
Fee Charged:$25.00 BRIAN TATRO Sheetmetal- 11990 12/28/2016
(Balance Due:$.00T Owner: AIMUA JOSEPH
#of Fixtures _ 'Applicant: BRIAN TATRO
DigSafe# __AT: 206 NORTH MAIN ST-LOT 2
UseGroup
ConstClass
ISSUED ON. 02-Jun-2015 AMENDED ON. EXPIRES ON.
TO PERFORM THE FOLLOWING WORK:
DUCTWORK FOR NEW SFH
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-2015-006366 22-May-15 202 $25.00
Inspection Type: Inspector: Date Inspected: Date Signed Off: Status:
ROUGH Charles Miller 27-May-15 PARTIAL COMPLY
212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:Ihasbrouck @northamptonma.gov
GeoTMS®2015 Des Lauriers Municipal Solutions,Inc.