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22B-113 (3) Please visit our web site at http://www.mass.gov/dpI/boards/SM MARCI A CHEVALIER (S M) 197 LOOMIS RIDGE WESTFIELD MA 01085 -3963 Fold,Then Detach Along All Perforations 41 ,m LT Q ,.a �►S l Ht3S TTS �HE�T I��TAL 1�1a»K�RS TIC K QU WING l I C N D AS A, MA�"CER�(iN�t~S�'R:I CTED MAR&1 i4 CHEVALIER W 1 �j'} r y t /g yvyur H r o W STF I E I.A MA 010- 3q 3 7 1 6/2$/ 6 2. $1.23 �, • u F EACH 0)-T S, -- _ e — Arnnr LIS�_USA s _ �-ooe E7j�ESi t5 .. .- n CHEVALIER x e 187 LOOMIS RIDGE WESTFIELD,MA 010853963 5 00 Ot�1T�30]11W 0]-1S700f J--!x F a b r ACTIAIR-01 MPROULX CERTIFICATE OF LIABILITY INSURANCE DA T DlYYYY) 41/28/22812015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CER IFr*PTE Df?E_S yQT,pFFIRMATIVELY OR NEGATIVELY,AMENO, .EXTEN*40R,Al.:'rr THE F�OVERAf�E AFFORDED BY THE POLICIES - rpe C •S 4tN Y ✓ly a= :; a (1°i"- „n /H� F�:LCsYy. ,x.:a.:' CE:s�iTIFICATE O� R�I�IJR. 'SCE DC,'.' NOT REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(!es)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Insurance Center of New England,Inc PHONE r800 243-8134 FAX 1070 Suffield' treet A/C No Ext: ) A/c No): (413)731-9539 Agawam,MA 01001 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:tA++LL AMERICA 20222 INSURED INSURERB:.Cert'tral Insurance Company 20230 Action Air loo INSURER C P.O.Box 636 INSURER D: Feeding Hills,MA 01030 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE L U POLICY NUMBER MMIDD/YYYY MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE a OCCUR CLP 7978942 04130/2015 04/30/2016 PREMISES Ea occurrence $ 300,00 MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE $ 2,000,00 POLICY FI PRO- ❑ JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,00 OTHER. AUTOMOBILE LIABILITY Ee aBINEDI SINGLE LIMIT $ 1,000,00 B ANY AUTO BAP 8611192 04/30/2015 04/3012016 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS per zccident $ $ X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 2,000,000 B EXCESS LIAB CLAIMS-MADE CXS 7978943 0413012015 04/30/2016 AGGREGATE $ 2,000,00 DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N X STATUTE EERH B ANY PROPRIETOR/PARTNER/EXECUTIVE NIA WC 7978944 04/30/2015 04/3012016 E.L.EACH ACCIDENT $ 500,00 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If E.L.DISEASE-EA EMPLOYEE $ 500,00 DESCRIes,describe under PTION OF OPERATIONS below E.L.DISEASE-POLICY'LIMIT $ 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) To show evidence of coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Verification of Insurance Purposes ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENNTATIVE ly a p,t & crc_ ©1988--20.14 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address:_ V �_ City/State/Zip: Phone#: -- —0- c. Are you an employer?Check t e appropriate box: Type of project(required): 1.Pl am a employer with 1�J 4. [] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors hew 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 or me in an capacity. employees and have workers' g Y P h'• 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.[1 Other comp. insurance required.] *Any appbcant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this andavit 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-controctors 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: Policy#or Self-ins. Lic.#: C1 -I 1 `1 `7 Expiration Date:: Job Site Address:a Q fN 'V _ - -- -City/State/Zip: �--�C)(P,KQk 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 A for insurance c verage verifica • I do hereby cer4 jinder the pa' enalties of p j that the information provided above is true and correct Signature: Date: 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: 1 have a current liabili insurance policy or its equivalent which meets the requirements of M.G.L, Ch. 112 Yes,�lo❑ 1f you have checked Yes, indicate the type of coverage by che- - =iq the appropriate box below- C ' A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owrer's Agent. By checking this bo I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the besf1portinont y knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Proeress Inspections Date Comments Final Inspection Date Comments Type of License By aster Tine ❑Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit ❑Journeyperson-Res tricted License Number. Fee; Check at www.mass.gov/dpi Inspector Signature of Permit Approval Sheet MetatTerW, �j Date: �o �� �l`J �,,.,� . ermit# JUN 17 'All) Estimated Job Cost: $ (�,V Pe it Fee: $ r , V D Electric, P ui-icinc & i, pections f , : File#SM-2015-0048 APPLICANT/CONTACT PERSON ACTION AIR ADDRESS/PHONE P O BOX 636 (413)789-9305 PROPERTY LOCATION MEADOW ST MAP 22B PARCEL 113 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid 0 Building Permit Filled out Fee Paid Typeof Construction: INSTALL DUCTWORK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 7110 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOIj�vIATION 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 Permit from Elm Street Co ission Permit DPW Storm Water Management //17—/� Signa ui ding O facia 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. MEADOW ST SM-2015-0048 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON GIS#: 120411 Map: 22B Block: 113 SHEETMETAL PERMIT Lot: — 00 . . _ il Permit: SHEETMETAL �IIII rv�" Category: ACCESSORY APARTME Permit# SM-2015-0018 ' PERMISSION IS HEREBY GRANTED TO: Project# JS-2015-001050 ___ Est. Cost: $5,000.40 Contractor: License: Expires: Fee Charged:$0.40 ACTION AIR Sheetmetal-7110 06/28/2016 Balance Due:$.00 Owner: CITY OF NORTHAMPTON #of Fixtures Applicant. ACTION AIR DigSafe# — JAT: MEADOW ST UseGroup ConstClass ISSUED ON. 18-.Tun-2015 AMENDED ON: EXPIRES ON. TO PERFORM THE FOLLOWING WORK: INSTALL 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: City Permit REC-2015-006824 17-Jun-15 0 $0.00 212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email.thasbrouck @northamptonma.gov GeoTMSO 2015 Des Lauriers Municipal Solutions,Inc.