36-362 (5) File#SM-2016-0027
APPLICANT/CONTACT PERSON AARON MORIN
ADDRESS/PHONE 140 WEST ST (413)247-0550 0
PROPERTY LOCATION 115 EMERSON WAY
MAP 36 PARCEL 362 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT g[/
Fee Paid o° ({pa
Building Petmit Filled out
Fee Paid
TvpeofConstruction: SPLIT SYS&DUCTWORK SFH
Nev Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Ow •r/Stater em or License 533
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
Permit from Elm Street Commission Permit DPW Storm Water Management
Signature of 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.
—
Commonwealth of Massachusetts
LO_E_G e 20151 City Of Northampton
3
Sheet Metal Permit Permitq
Estimated Job Cost: $15;00O Permit Fee: $ d 144"
Plan
c 9-
Plans Submitted: YES NOrlyLr Plans Reviewed: YES_ NO
5.33
Business License# J .33 Applicant License
Business Information: Property Owner;Job Location Information:
Name: / /14.0r.t� ) L n,k/ Name: �.c.�IL JC!-JKA' ��fS
Street:. /4/6
,701N�'.�t,�5�( � t/r Street: // r'�'
5 C nG'�/i
•'�i I
City/Town: Wes (f-"-r ��' Id City/Town: 116-5(1 ✓tfikr----__F
Telephone: 4//3- 7-14L Telephon
4. e: — /D0D
Photo LD. required/Copy of Photo I.D. attached: YES 1, NO
�� Starttnidal -
J-1 C�M1lytmrestricted license
J-2/M-2-restricted to dwellin 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. R!/ over 10,000 sq. ft. Number of Stories:
Sheet metal work to be completed: New Work: i- Renovation:
HVAC [7-----Metal Watershed Roofing_ Kitchen Exhaust System
Metal Chimney/Vents Air Balancing
Provide detailed description of work/ to be done: ` /cp(( tsy-.sJjE'-N'v,... C--YI r./ i�J`r
4c cie
O lemma (OC_ ffy
Fees with Building Perrot$25.00 Resioenlial, $50.00 Commercial. Fees Ior jobs without a Building Permit$5.00 per$1000
Minimum fees for jobs without Building Permit$50.00 Residential, $100.00 Commercial
INSURANCE COVERAGE:
I have a current Jlahfllty insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes
If you have checked Yes, indicate the ty f coverage by checking the appropriate box below:
A liability insurance policy Other type of indemnity 0 Bond ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee sines not been the insurance coverage required by Chapter 112 of the
Massachusetts General Laws,and that my signature on this permit application walvesthia requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this boxD,I hereby certifythat 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
prn epee Tncrertinnc
Date Pi-memento
Final 1nercrfinrt
Date rnmmentc
.............
Type of LIC e:
Byaster
Pile_, ❑
Master-Restricted
city/Town arourneypersnn
Signature of Licensee
Permit#
nourneypersan-Restricted License Number: .573
Fees a
Check at pnv'v mase gnvfdpt
Inspector Signature of Permit Approval
The Commonwealth of Massachusetts
trs
it a -r' Department ofIndustrial Accidents
+aM�.aram% 1 Congress Street,Suite 100
a^e' '— Boston,MA 02114-2017
�NIt ,
,s3 www.massgow'&a
Workers'Compensation Insurance Affidavit:RoiiderstContrtetors/Electriciaos/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(auaines,/Organirationindividuaj): Aaron Marin Sheet Metal
Address: 140 West Street
City/State/Zip: West Hatfield,MA 01040 Phone#: 413.427-1416 cell
Ate a mohair?Caak the}appropriate hex: Type of
project(required):
i sempioet with 2' employeesMill anm«part-timet (_j
• 7. rvew construction
2❑lam a sole proprietor or partnership and have no employees working for me in h. ❑Remodeling
any capacity.(No workers comp.insurance required]
lot am a homeowner doing all work myself[No workers comp.insurance recurred.]' 9. ❑Demolition
a.Qiema ho: »tor and will xroring uonnanoamwndut an wink nm I will lO�Building addition
rowo�
rnwtedw all with nemployees aye xmkus'mmp[mmron rmuren¢ar wt II�Eta total repairs or additions
proprietors with no employees I2.O Plumbing repairs or additions
SQ t am a general contractor and l have Nast the sub-contactors listed on the attached shed 13 Roof repairs
These subcontractors have employees and liars wcoraq:3orkers' mp.insurance.:
-❑ '-
}//�/� y^
6we area c rp mSiori aid 45owcn have exereise6 Nov eight ofeumptga ser MGLe. 14.(y2Othet l T[
V$2,gi(4),and we haven employees.INe workers'conch msurace required I
_
'Any applicant that checks box In must also fill out the section below showing their workers compensation policy information
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 Ihi box must attached all additional sheet slowing the name of the subcontractors and state whether or not too entities have
cnptoyuesti thy subcenoloon bac meplavees.they must ptuvkkteff kars'svmp.Petr}'numbed
I am an employer Men is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: National Grange Mutual Insurance
Policy#or Self-ine. Lie.#:WCT1090D Expiration Date:3-22.2°16
lob Site Address: /I Se-/' tefSrM' Ciry/State/Zip//0 rielaaN�r6.�/r't/1^p r�J �r--t-1
Attach a copy of the workers'compensation policy decla ion page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL e. 152,§25A is a criminal violation punishable by a fine up to$1,50000
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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
_ _ ...... _
t do hereby certijy � the pains ond •'es of pedal);thmthe information providedabove Is cornete and
Signatiue: Dare: t/a7 les
/shopo g. 413-4271416
Official use only. Do marmite in this area,to be completed by city or town official
Cily or Town: Permit/License it
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone ft:
_