36-389 (2) SM-2022-0005
168 EMERSON WAY COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
36-389-001 CITY OF NORTHAMPTON
Permit: Sheet Metal
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# SM-2022-0005 PERMISSIONISHEREBYGRANTED TO:
Project# sheet metal Contractor: License:
Est.Cost: 3650 ALL SEASONS HEATING AIR
Const.Class: Exp.Date:
HEWITT ROBERT&CAROL JEAN SHRIVER
Use Group: Owner: HEWITT
Lot Size (sq.ft.)
Zoning: SR Applicant: ALL SEASONS HEATING AIR
Applicant Address Phone: Insurance:
93 ELM ST (413)247-9842 WCT6529S
HATFIELD, MA 01038
ISSUED ON:03/11/2022
TO PERFORM THE FOLLOWING WORK:
HVAC
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter: Footings:
Rough: Rough: House# Foundation:
Gas: Final: Final: Rough Frame:
Rough: Fire Department Driveway Final: Fireplace/Chimney:
Final: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
I • fi yg . grr`1 •
Fees Paid: $25.0(1
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
REC I v .
Commonwealth of Massachusetts
MAR 1 o 202.2 City Of Northampton
t. Tofe it ,iris Sheet Metal Permit
1,._._ r,oRTF,: ��'. Permit# s� —
_.._._ BP - &cal - ai(oO
Estimated Job Cost: $ 3(c 0.-,c) Permit Fee: $ S.pn
Plans Submitted: YES NO h Plans Reviewed: YES NO
W night s`3 udders
Business License# Applicant License # Co5541
Business Information: Property Owner/Job Location Information:
ROber- Hews
Name:At( Ro on6 Aecoirye AC Name: CCAVOI Shriven
Street: q 6 Et m 6+ Street: ((Os E m PX&r tnr or I
City/Town: H Q+Cif Id M A O tO 8 City/Town: FI O Y Pj'1 C'Q 1`'1A O IJO(oa
Telephone: wr �� \
Tele
p 4( 3 -a4-4-q-18' Telephone: 1}13. 5No-Ra8 (Fuigaersi
Photo I.D. required/Copy of Photo I.D. attached: YES NO
Staff Initial
J-1 /11 Linrestricted 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 l� Multi-family Condo/Townhouses Other
Commercial: Office Retail Industrial Educational
Institutional Other
Square Footage: under 10,000 sq. ft. y over 10,000 sq. ft. Number of Stories: I
Sheet metal work to be completed: New Work: V Renovation:
HVAC X Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney/Vents Air Balancing
Provide detailed description of work to be done:
i r'1tGltQ+io1Th c,C d uc4ed 1) rcnd bQ+h vrjo m
C-Cktns r new dui ell4-,5.
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, $100.00 Commercial
INSURANCE COVERAGE:
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes " No El
If you have checked Yes, indicate the type of coverage by checking the appropriate box below:
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee dnec not have the insurance coverage required by Chapter 112 of the
Massachusetts General Laws, and that my signature on this permit application waivesthis requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this boxi,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best cif my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be
in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
Duct inspection required prior to insulation installation: YES NO
Progress Inspections
Date f ommP.nts
Final 1nsrHrtinn
flats' I`nrhm('nts
eetil/--)
Type of License:
By tea 55 44 Master
Title LOCAL ..Z1..J.5pc-c;ort ❑ Master-Restricted
City/Town 00e-THArlPiati ❑Journeyperson
gnature of Licensee
Permit# ❑Journeyperson Restricted License Number: /01-
Fee$ ❑
Check at www mass gnvldpl
.3-I1-2C72
Inspector Signature of Permit Approval
The Commonwealth of Massachusetts
Department of Industrial Accidents
q
—�. `;�� Office of Investigations
-=�. — , Lafayette City Center
, IMMW
~ _'Y, (� 2 Avenue de Lafayette, Boston, MA 02111-1750
s.
"`' �' wwx.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): All Seasons Heating &Air Conditioning, Inc.
Address:93 Elm Street
City/State/Zip: Hatfield, MA 01038 Phone #:413.247.9842
Are you an employer? Check the appropriate box: Type of project(required):
1.❑� I am a employer with 8 4. ❑ I am a general contractor and I 6. ❑■ New construction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. 0 Remodeling
2.0 I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. [' Demolition
working for me in any capacity. employees and have workers'
9. ❑Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. 0 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.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.0 Other
employees. [No workers'
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 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.
Insurance Company Name: National Grange Mutual Insurance Company
Policy#or Self-ins. Lic. #:WCT6529S Expiration Date: 07/10/2022
Job Site Address: 168 Emerson Way City/State/Zip: Florence, MA 01062
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 u der t e paa. and penalties of perjuty that the information provided above is true and correct.
illSignature: Date: 02/25/2022
Phone#: 413.247.9842
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority(check one):
11:1Board of Health 20 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 5E1Plumbing
Inspector 6.0Other
Contact Person: Phone#:
WORKERS COMPENSATION AND EMPLOYERS' LIABILITY
INSURANCE POLICY—INFORMATION PAGE
INSURER: POLICY NO: WCT6529S
NGM INSURANCE COMPANY
4601 TOUCHTON ROAD EAST SUITE 3400 RENEWAL OF: WCT6529S
JACKSONVILLE, FL 32245-6000 NCCI Company No: 16322
Account No: CACT6529S
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENCY NAME AND ADDRESS:
ALL SEASONS HEATING & AIR AQUADRO & ASSOCS INS AGCY INC
(SEE NAMED INSURED ENDT)
93 ELM ST PO BOX 357
HATFIELD MA 01038-9715 NORTHAMPTON, MA 01061
AGENCY PHONE NO.: (413) 586-7373
AGENCY NO.: 201107
LEGAL ENTITY: CORPORATION
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Location Schedule)
ITEM 2. POLICY PERIOD: From: 07-10-2021 To: 07-10-2022
Effective 12:01 A.M. Standard Time at the Insured's mailing address.
ITEM 3. COVERAGE:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states
listed here:
MA
B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of
liability under Part Two are:
Bodily Injury by Accident: $ 1, 000, 000 each accident
Bodily Injury by Disease: $ 1, 000, 000 policy limit
Bodily Injury by Disease: $ 1, 000, 000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
all states except: ND, OH, WA, WY
and states designated in ITEM 3A of the information page.
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to
verification and change by audit. Please see Classification Schedule.
Total Estimated
Minimum Premium: $ 461 Annual Premium: $ 10, 733
Audit Period: ANNUAL
Date: 07-02-2021 Countersigned by
WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance
INSURED COPY