24D-092 (16) SM-2024-0015
84 NORTH ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
24D-092-001 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-2024-0015 PERMISSION IS HEREBY GRANTED TO:
Project# RENO 2024 Contractor: License:
Est. Cost: 425000 JAMROG HVAC
Const.Class: Exp.Date:
Use Group: Owner: INC SULLIVAN D A&SONS
Lot Size (sq.ft.)
Zoning: URC Applicant: JAMROG HVAC
Applicant Address hone: Insurance:
194 MILERS FALLS RD, STE 2 (413)548-9024
TURNERS FALLS, MA 01376
ISSUED ON: 04/03/2024
TO PERFORM THE FOLLOWING WORK:
DUCT IN 2 AHU'S & 1 ERV FOR NEW CONDO ON 2ND FLOOR
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
Commonwealth of Massachusetts 2 `4 - - Z- oo /
Sheet Metal Permit
Late: 3/951 a Permit#50 -2 —QOtS
stimated Job Cost: $ I(.00,ow Permit Fee: $5 C.4.1 39
Plans Submitted: YES ✓ NO Plans Reviewed: YES NO
Business License# $41 Applicant License# Lo tb i Ja. 3e)
Business Information: Property Owner/Job Location Information:
Name:J i\C Name: 5t.((i vO 4L D-A &(-
Street: ' 4 e t l C r.1 Ra..(lS Street: 94
City/Town: l ' f Fa.I( /,t,t„ , City/Town: N o410-. , /A'A
Telephone: 4 i 3"st(g"qo DA. Telephone: 14( 5
Photo I.D. required/Copy of Photo I.D. attached: YES V NO
Starr Initial
J-1 /a 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 Multi-family Condo/Townhouses Other
Commercial: Office Retail Industrial Educational
Institutional Other ✓ 1C CL (&l.
LUG Square Footage: under 10,000 sq.ft. V over 10,000 sq.ft. Number of Stories:
Sheet metal work to be completed: New Work: Renovation:
HVAC V. Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney/Vents Air Balancing
Provide detailed description of work to be done:
�l t a - At-(J,f c4 (-E(LV --o serve, New condo
t 2i Plcor
INSURANCE COVERAGE:
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes [No 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 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 bowl 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
Progress Inspections
Date Comments
Final Inspection
Date Comments
Type of License:
By Tit ❑Master
Master-Restricted
City/Town
❑Journeyperson Signature of Licensee
Permit# _
❑Journeyperson Restricted License Number: Check at
//7
Inspector Signature of Permit Approval
MASSACHUSETTS DRIVER'S
LICENSE
� ,,ISs 1,I NUMBER
i 12102/2021 S67965841
. v, 12 511/20026 12/11/1975
D NONE 1^REST AI NONE
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HADLEY,MA 01035.9813
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'BO t2,03/2021 Rev02/22/2016 ; a
The Commonwealth of Massachusetts
Department of Industrial Accidents
3 =TOW 1 Congress Street,Suite 100
— ` Boston,MA 02114-2017
,w= www.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/Organization/Individual):Jamrog HVAC
Address: 194 Millers Falls Rd
City/State/Zip:Turners Falls, MA 01376 Phone#:413-548-9024
Are you an employer?Check the appropriate box:
Type of project(required):
1. ✓❑I am a employer with 12 employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]'
9. El Demolition
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will
10 El Building addition
ensure that all contractors either have workers'compensation insurance or arc sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.12 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROOF repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.12 We arc a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,*1(4),and we have no 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 arc 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 pros ide 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:Arbella Protection Insurance
Policy#or Self-ins.Lic.#:4220100983 Expiration Date: 11/11/2024
Job Site Address:84 North St City/State/Zip:Northampton, MA 0106C
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 verificati9f.
I do hereby certifyJpnder the pains and penalties of perjury that the information provided above is true and correct.
Signature: '` U't/IIiW lie 'o4c t 441-" V' Date: `t!°a' I p4
Phone#:413-54.8-9024
Official use only. Do not write in this urea,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. However 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 be 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 required 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 confirmation 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 are 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 permit/license 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