15B-050 (2) 306 CHESTERFIELD RD SM-2017-0035
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
os#: 12176scit
io}.
Map: 15B
Bock 050
-- /"11) SHEETMETAL PERMIT
Lot: 001 �, r
Permit: SHEETMETAL
Category: New Single Family House '..
Permit# SM-2017-0035 PERMISSION IS HEREBY GRANTED TO:
Project# JS-2017-000485
Est.Cost: $6,000.00 Contractor: License: Expires:
Fee Charged.$25.00 ,.NORMAN EMOND Sheetmetal- 12370 03/28/2017
Balance Due:$.00 Owner: Patrick Melnik
#of Fixtures: _ '.Applicant: NORMAN EMOND
DigSafe# AT: 306 CHESTERFIELD RD
UseGroup - �
ConstClass
ISSUED ON: 22-Dec-2016 AMENDED ON: EXPIRES ON:
TO PERFORM THE FOLLOWING WORK:
INSTALLING DUCTWORK FOR NEW HEATING SYSTEMS&A HEAT RECOVERY SYSTEM
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: .%mount:
Sheetmelal REC-2017-002471 09-Dec-16 1683 825 00
212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck@northamptonma.gov
GeoTMSCa 2016 Des Tanners Municipal Solutions,Inc.
File#SM-2017-0035
APPLICANT/CONTACT PERSON NORMAN EMOND
ADDRESS/PHONE 7A RAILROAD ST (413)774-9482
PROPERTY LOCATION 306 CHESTERFIELD RD
MAP 15B PARCEL 050 001 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid k
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALLIN WORK FOR NEW HEATING SYSTEMS&A HEAT RECOVERY
SYSTEM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owned Statement or License 12370
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOR TION 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 C fission Permit DPW Storm Water Management
7'. s,
/ j_ /2-O o/d
ure 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
City Of Northampton
nate: /et /I Sheet Metal Permit Permit
Estimated Job Cost: $ E COO, ep Pennit Fee: $ ,2S -00
Plans Submitted: YES NO Plans Reviewed: YES NO
Business License# �j�Q q _ Applicant License# l 2 3 3-0
Business Information: Property Owner/Job Location Information:
Name: ONe5 VAN' ACP— Name: p�A-r:c_t Sy _K
Street: 54 Street: 2,çi I„ G\vzr s\ e \d.
City/Town:_ , r _ — . NA City/Town: f,p'a -
Telephone: d Ctrl q C Telephone: LR (73 S12Li6.150
Photo I.D. required /Copy of Photo I.D. attached: YES )( _ NO
Staff Initial
J-] /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 X 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: I
Sheet metal work to be completed: New Work: )( Renovation:
HVAC x Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney/Vents Air Balancing
Provide detailed description of work to be done: q
1#(#5 \,� .c�s1.L-. :._\ jo K. foY cu \'�Lo-t„^4#3 Qr
C.2\ ..req r� S -¢,t.r.,.j Co.v.& 0. e.c.A `cY cecsi? r a3 S�\f.rn
-
Fees with Building Permit:$25.00 Residentiall$50.00 Commercial.Fees for jobs without a Building Permit$6.00 per S1000
Minimum fees for jobs without Budding Permit$50.00 Residential, $100.00 Commercial
INSURANCE COVERAGE: ../
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes L1g No❑
If you have checked Yes,indicate the type of coverage by checking the appropriate box below:
A liability insurance policy L\4 Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this boxO.I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be
in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
Duct inspection required prior to insulation installation:YES NO V
Progress Inspections
Date Comments
Final Inspection
Date Comments
Type of License:
By Master
T'Je Master-Restricted❑ �i//�—f`" W///
� � �/
City/Town ❑Joumeypersan
Signature of Licensee
Permit ft /,2 ?7jt
❑Joumeyperson-Restricted CC//
License Number:
Fee$ ❑
Check at www.mass.govldpl
Inspector Signature of Permit Approval
ACRO® CERTIFICATE OF LIABILITY INSURANCE 0;,;;2°°6"'
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)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). ppXXY♦p�E'CT
PRODUCER 00444-001 or Branch 444-1
Albert B Allen Inc PHO.Nf.EMC (413)]]3-52]5 ii0 .No.:
P 0 Box 388 RDD[ RILESS.
Greenfield,MA 01302
INSURFRISI AFFORDING COVERAGE NAIC#
wsuRERA: A.I.M.Mutual Insurance Company 33753
INSURED INSURER B'
Gates HVACR LLC
MSURFRO'
7A Railroad Street D'
South Deerfield, MA 01373 I
INSURER E:
INSURER F'
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT HATH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR EXCLUSIONS AND CONDITIONS OF SUCH POLICIESY LIMITSSHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMTHE INSURANCE AFFORDED BY THE POLICIES S. HEREIN IS SUBJECT TO ALL THE TERMS.
I TYPE OF INSURANCE Skiff POLICY NUMBER IM2k j.I (yaw$,, c-1 LIMITS
GENERAL LABILITY EACH OCCURRENCE $
DAMAGE TO COMMERCIAL GENERAL LIABILITYPREM$ES(EaEORVTE arra) $
■ CLAIMS-MADE OCCUR MED EXP(Any one person) 5
■ PERSONAL a ADV INJURY $
■ GENERAL AGGREGATE $
ENL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG S
■-OLICY -RO- LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I$
(Ea aw@nll
■ANY AUTO BODILY INJURY(Per person) S
III,ALL OWNED SCHEDULED BODILY INJURY(Per accent) S
AUTOS AUTOS
.HIRED AUTOS NON.ONNED PROPERTY DAMAGE $
AUTOS (Per amOun0
■ $
' UMBRELLA LIAB I OCCUR EACH OCCURRENCE 15
EXCESS LIAB CLAIMS MADE AGGREGATE $
wD
DEO
S spy RETENTION $ µµCCGG IIJJ I� $
qANNyMEMOPpLpO�YEEi[R�PSWELIgARBII,LVIEIY NN x IIORYLI�ITSI ITP
q UFfi1EE2MEMBERPEXCLI1OEEiFCUTNE I E.L EACH ACCIDENT $ 100000.00
ED Y ulA gWCi004031073-2016A 8/5/2016 8/6/2017
(Mandatory
y iino NaXIn)p EL DISEASE-EA EMPLOYEE $ 100 000.00
O t pLRIPTIOHOFUPERATION$Celow _._ EL DISEASE-POLICY LIMIT $ 600,000.00
DESCRIPTOR OF OPERATIONS LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks ScheeuN,H more space Is required)
John M Gates is not covered by the workers compensation policy.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE C-2 �elt
6)1988-2010 ACORD CORPORATION.All rights reserved.
D name and logo are registered marks of ACORD
5.52115a558""""m. _ ')^: Fold,Then Detach Along All Perforations
ISC40 VIHy�. 9 COMMONWEALTH OF MASSACHUSETTS
toisca arvlxrmwA: - DIVISION OF PROFESSIONAL LICENSURE
BOARD OF
d9IILIM9 Qrva
191151 cs it ,a c, l ' SHEET METAL WORKERS
VL6L'L1-£2 610141/9 SSUES THE FOLLOWING LICENSE
[�
'AS..A MASTER-UNRESTRICTED 777
969£949ZS�gxON 4LBE '$Fm. °
!MalNORMAN L EMOND.JRw.
3SN30I1
SIdBMSD - 5974 LEYDEN RD
GREENFIELD MA 01301-9503
- ---.- — 12170 -' 03/28/17 -° 192562
The Commonwealth of Massachusetts
1=1=11' (1 Department of Industrial Accidents
1 Congress Street,Suite 100
krt Boston,MA 02114-2017
immarwww.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business:Ogani,ation/Individual): G m�e.S V At LA)._
Address: P, SA"
of 313
City/State/Zip: , • A V r'c G$ MA Phone#: LV 3 l (. qct c z,
Are you an employer?Chedtbe appropriate bo.: Type of project(required):
I_®I am a employer wino 5 employees(lull and/or pan-time)' 7. ❑New construction
2.0 I ant a sole proprietor or partnership arid have nu employees working for me in 8. J Remodeling
ally capacity.[So workers comp.insurance required
9. Demolition
3.0 I am a homeowner doing all work myself[No workers'comp.insurance requited.]
4.0 I' a homeownerand ill b hiringcontractors toconduct all work my property. I will IO Building addition
that all contractors either haveworkerscompensation insurance or are sole 11.0 Electrical repairs or additions
proprietorsa with no employees. 12.❑Plumbing repairs or additions
5.0I am a general contractor and I have hired the sub-contractors listed on the attached shecw. 13E Roof repairs
These sub-contractors have employees and have workers'comp.insurance.'
e_0Wearc corporationand its offishave exerdredtheir right ofexemption per MGL c. 4.®Other 1{JFtG 'D"e4'
152.nsI(4),and we have w
no employees.[No workers'comp.insurance required.]
'Any applicant hat checks box#1 must also fill out the section below showing their workers'compensation policy information.
'Homeowners who submit this affidavit indicating they aro 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 stalewhether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Al. .1'\V‘\--‘10.\ -- vCO.v.C..e. (_,p vv-,„
Policy#or Self-ins. Lie.#:N./6 C `too -IC 12) ICs " -:)ClioA Expiration Date: 09 /05 I .51)nII-
ALL LOCATIONS City/State/Zip:Amherst, MA 01002
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 S250.00 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.
l do hereby ce I. u - if; r dpenalties of perjury that the information provided above is true and correct
firSignature: : Date: (a) CI I a c I
Phone l a {'HCl c\1\
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#:
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. I Iowever 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 he 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 equired 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 confimtation 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 arc 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 permidlicense 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia