17C-120 (9) SM-2022-0015
34 SHEFFIELD LN COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17C-120-001 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-2022-0015 PERMISSION IS HEREBY GRANTED TO:
Project# SHEET METAL Contractor: License:
Est. Cost: 5000 NORMAN LA EMOND JR
Const.Class: Exp.Date:
Use Group: Owner: C BENNETT MARK K&JANET
Lot Size (sq.ft.)
Zoning: URB Applicant: GATES HVACR LLC
Applicant Address Phone: Insurance:
135 MILLERS FALLS RD 413-774-9482 WCP8873G
TURNERS FALLS, MA 01376
ISSUED ON:06/03/2022
TO PERFORM THE FOLLOWING WORK:
INSTALL DUCTS FOR COOLING SYSTEM
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: )
Fees Paid: $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
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DIVISION OF PROFESSIONAL LICENSURE
BOARD OF
SHEET METAL WORKERS \\'
ISSUES THE FOLLOWING LICENSE
MASTER-UNRESTRICTED c \ '
NORMAN L EMONO JR cis
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597 LEYDEN RD
APTA z
GREENFIELD.MA 01301-9503 z
12370 03/28/2023 104
fu Commonwealth of Massachusetts
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N City Of Northampton
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Sheet Metal Permit S� -
LLM Date: 05 - PermitSin
Estmnated Jo Cost: $ 5000. 00 Permit Fee: $ 50.OJ
Plans Subiai d: YES V NO Plans Reviewed: YES NO
Business License# Applicant License# �310
Business Information: Go\cs - 'JAcQ. Property Owner/Job Location Information:
Name: (Voxvc•ay\ L.A k.4c...0,A d. Name: -So rre:'A
Street: 13s Milker s Vc‘11. Street: 3 L 5 ;�\a,
City/Town: Z. Fc.\`g (vim City/Town: to'c V\C ) V A
Telephone: 413 -t{94 53.3 Telephone: Lit 3
Photo I.D. required/Copy of Photo I.D. attached: YES V NO
Staff Initial
J-1 /M-1-u estricted license
J- /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 1' 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:
1-VAC V Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney/Vents Air Balancing
Provide detailed description of work to be done:
ors\c).\\ cc5 o - Cc O Su 'Dk•ex`r•
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,$100.00 Commercial
INSURANCE COVERAGE:
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes ULJ No El
If you have checked Yes,indicate the type of coverage by checking the appropriate box below:
A liability insurance policy 2( Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee rtnec not have the insurance coverage required by Chapter 112 of the
Massachusetts General Laws, and that my signature on this permit application waivesthis requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this box❑,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be
in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
Duct inspection required prior to insulation installation: YES NO
Progri'cg Incppctions.
bait, Commety;
Fin 9I I n psctinn
Date Comments
Type of License:
By Master
True ❑Master-Restricted '
City/Town ❑Journeyperson
Signature of Licensee
Permit#
❑Joumeyperson-Restricted
Fee$ License Number: I`2.3 t)
e Check at www mass gnvldpt
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Inspector Signature of Permit Approval
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The Commonwealth of Massachusetts
1, * ,/ Department of Industrial Accidents
-V 1 Congress Street,Suite 100
m
`. t; - Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
Name(Business/Organizational/Individual):Gates Hvacr LLC
Address: 135 Millers Falls Rd City: Turners Falls
State: MA Zip 01376 Phone#: 4137749482
Are you an employer?Check the appropriate box: Type of project(required):
n1. I am an employer with 6 employees(full and/or part time)* n 7. New construction
'❑12. I am a sole proprietor or partnership and have no employees working for me in any '❑8. Remodeling
capacity. (No workers'comp.insurance required.]
9. Demolition
❑3. I am a homeowner doing all work myself.[No workers'comp.insurance required]t 010. Building addition
n4. I am a homeowner and will be hiring contractors to conduct all work on my property. 011. Electrical repairs or additions
I will ensure that all contractors either have workers'compensation insurance or are
sole proprietors with no employees. 012. Plumbing repairs or additions
n5. I am a general contractor and I have hired the sub-contractors listed on the attached ❑13. Roof Repairs
sheet. These sub-contractors have employees and have workers'comp. insurance.±
n6. We are a corporation and its officers have exercised their right of exemption per MGL. [ )14. Other
c. 152,§1(4),and we have no employees. [No workers'comp.insurance required.] 1
"Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHomeowners 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 attach 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,
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information.
Insurance Company Name: NGM Insurance Company
Policy#or self ins.Lic.#: WCP8873G Expiration Date: 08/05/2023
Job Site Address: 34 Sheffield Lane, Florence, Ma
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$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.
aI do hereby certify under the pains and penalties of perjury that the information provided above is true and correct,and that clicking this
checkbox nd ypingmy n me in the field below will act as my signature.
Name: Date: 05/25/2022
Phone : 1377 9482 Email: gateshvacr@hotmail.com