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16B-001 BASEMENT 11 , i i 1 CE LLAR I Job #: Scale: 1 : 109 Performed for: Page 3 Right- Suite® Universal 7.1.19 RSU11776 2013- Mar -08 13:43:20 ool Ioads\ACTIONBEARHILL #26A.... SECOND STUDIO OFFICE FINISHED STORAGE Job #: Scale: 1 : 109 Performed for: Page 2 Right- Suite® Universal 7.1.19 RSU11776 2013- Mar -08 13:43:20 001 Ioads\ACTION BEARHILL #26A.... Level 1 1 BREAK SUN KIT LAUNDRY MASTER DINING LIV HALL MSTRBTH MUSIC BATH FOYER BED2 r ===, Job #: Scale: 1 : 109 Performed for: Page 1 Right- Suite® Universal 7.1.19 RSU11776 2013- Mar -08 13:43:20 ool loads \ACTION BEARHILL #26A.... t Project Summary Date: MARCH 6,2013 ° ' " ' °' SECOND FLOOR By: Project Information For: Notes: Design Information Weather: Springfield Westover AFB, MA, US Winter Design Conditions Summer Design Conditions Outside db 0 °F Outside db 87 °F Inside db 70 °F Inside db 75 °F Design TD 70 °F Design TD 12 °F Daily range M Relative humidity 50 % Moisture difference 24 gr /Ib Heating Summary Sensible Cooling Equipment Load Sizing Structure 19636 Btuh Structure 10721 Btuh Ducts 187 Btuh Ducts 35 Btuh Central vent (0 cfm) 0 Btuh Central vent (0 cfm) 0 Btuh Humidification 0 Btuh Blower 0 Btuh Piping 0 Btuh Equipment load 19823 Btuh Use manufacturer's data n Rate /swing multiplier 0.92 Infiltration Equipment sensible load 9895 Btuh Method Simplified Latent Cooling Equipment Load Sizing Construction quality Tight Fireplaces 1 (Average) Structure 204 Btuh Ducts 38 Btuh Heating Cooling Central vent (0 cfm) 0 Btuh Area (ft 1552 1552 Equipment latent load 241 Btuh Volume (ft 13969 13969 Air changes /hour 0.14 0.05 Equipment total load 10137 Btuh Equiv. AVF (cfm) 33 13 Req. total capacity at 0.70 SHR 1.2 ton Heating Equipment Summary Cooling Equipment Summary Make n/a Make n/a Trade n/a Trade n/a Model n/a Cond n/a GAMA ID n/a Coil n/a AR1 ref no. n/a Efficiency n/a Efficiency n/a Heating input Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 °F Total cooling 0 Btuh Actual air flow 0 cfm Actual air flow 0 cfm Air flow factor 0 cfm /Btuh Air flow factor 0 cfm /Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat n/a Load sensible heat ratio 0 Printout certified byACCA to meet all requirements of Manual J 8th Ed. wrigtstsott' Right -Swtee Universal 7.1.19 RSU11776 2013 - Mar - 0813 42:29 AC .. HOLESALEtiDocurnentsW eatn' cool loads \CTIONBEARHILL #26A.rup CaIc =MJ8 Orientation = SE Page4 d Project Summary Job: .,. ` ' ' ° ' `' ' ' '''' FIRST FLOOR Byte: MARCH 6,2013 Project Information For Notes: Design Information Weather Springfield WestoverAFB, MA, US Winter Design Conditions Summer Design Conditions Outside db 0 °F Outside db 87 °F Inside db 70 °F Inside db 75 °F Design TD 70 °F Design TD 12 °F Daily range M Relative humidity 50 % Moisture difference 24 gr /Ib Heating Summary Sensible Cooling Equipment Load Sizing Structure 28506 Btuh Structure 22712 Btuh Ducts 2074 Btuh Ducts 879 Btuh Central vent (0 cfm) 0 Btuh Central vent (0 cfm) 0 Btuh Humidification 0 Btuh Blower 0 Btuh Piping 0 Btuh Equipment load 30580 Btuh Use manufacturer's data n Rate /swing multiplier 0 Infiltration Equipment sensible load 21704 Btuh Method Simplified Latent Cooling Equipment Load Sizing Construction quality Tight Fireplaces 1 (Average) Structure 619 Btuh Ducts 878 Btuh Heating Cooling Central vent (0 cfm) 0 Btuh Area (ft 1889 1889 Equipment latent load 1496 Btuh Volume (ft 17001 17001 Air changes /hour 0.12 0.05 Equipment total load 23200 Btuh Equiv. AVF (cfm) 35 13 Req. total capacity at 0.70 SHR 2.6 ton Heating Equipment Summary Cooling Equipment Summary Make n/a Make n/a Trade n/a Trade n/a Model n/a Cond n/a GAMA ID n/a Coil n/a ARI ref no. n/a Efficiency n/a Efficiency n/a Heating input Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 °F Total cooling 0 Btuh Actual air flow 0 cfm Actual air flow 0 cfm Air flow factor 0 cfm /Btuh Air flow factor 0 cfm /Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat n/a Load sensible heat ratio 0 Printout certified byACCA to meet all requirements of Manual J 8th Ed. Mt wri gg oft` Rig ht-Suite Universal 7.1.19 RSU11776 2013- Mar - 0813:42:29 ACC/h cc _I HOLESALE\Documents91eatn'cool loads\ACTIONBEARHILL #26A.rup Calc = MJ8 Orientation = SE Page 3 Project Summary ob: } ' J y Date: MARCH 6,2013 ,, „, . '_,: ,..-,,.r' BASEMENT 9y: Project Information For. Notes: Des Infor Weather: Springfield WestoverAFB, MA, US Winter Design Conditions Summer Design Conditions Outside db 0 °F Outside db 87 °F Inside db 70 °F Inside db 75 °F Design TD 70 °F Design TD 12 °F Daily range M Relative humidity 50 % Moisture difference 24 gr/lb Heating Summary Sensible Cooling Equipment Load Sizing Structure 18724 Btuh Structure 5090 Btuh Ducts 0 Btuh Ducts 0 Btuh Central vent (0 cfm) 0 Btuh Central vent (0 cfm) 0 Btuh Humidification 0 Btuh Blower 0 Btuh Piping 0 Btuh Equipment load 18724 Btuh Use manufacturer's data n Rate /swing multiplier 0.92 Infiltration Equipment sensible load 4683 Btuh Method Simplified Latent Cooling Equipment Load Sizing Construction quality Tight Fireplaces 1 (Average) Structure 105 Btuh Ducts 0 Btuh Heating Cooling Central vent (0 cfm) 0 Btuh Area (ft 1985 1985 Equipment latent load 105 Btuh Volume (ft 7940 7940 Air changes /hour 0.13 0.05 Equipment total load 4788 Btuh Equiv. AVF (cfm) 17 6 Req. total capacity at 0.70 SHR 0.6 ton Heating Equipment Summary Cooling Equipment Summary Make n/a Make n/a Trade n/a Trade n/a Model n/a Cond n/a GAMA ID n/a Coil n/a ARI ref no. n/a Efficiency n/a Efficiency n/a Heating input Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 °F Total cooling 0 Btuh Actual air flow 0 cfm Actual air flow 0 cfm Air flow factor 0 cfm /Btuh Air flow factor 0 cfm /Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat n/a Load sensible heat ratio 0 Printout certified byACCA to meet all requirements of Manual J 8th Ed. ., wile. ht soft` Right Suite® Universal 7.1.19 RSU11776 2013- Mar -08 13 42:29 AC�,II,, .. HOLESALE1DowmeMSWeatn' cool loads 1 ACTIONBEARHILL #26A.rup Calc =MJ8 Orientation - SE Paget 6f4f , E ' 7 Project Summary Job: Date: MARCH 6,2013 ''' .H., ..,,. <r., ,. -.' r' Entire House By: Project Information For: Notes: Design Informat Weather. Springfield WestoverAFB, MA, US Winter Design Conditions Summer Design Conditions Outside db 0 °F Outside db 87 °F Inside db 70 °F Inside db 75 °F Design TD 70 °F Design TD 12 °F Daily range M Relative humidity 50 % Moisture difference 24 gr /Ib Heating Summary Sensible Cooling Equipment Load Sizing Structure 66866 Btuh Structure 34551 Btuh Ducts 2261 Btuh Ducts 815 Btuh Central vent (0 cfm) 0 Btuh Central vent (0 cfm) 0 Btuh Humidification 0 Btuh Blower 0 Btuh Piping 0 Btuh Equipment load 69127 Btuh Use manufacturer's data n Rate /swing multiplier 0.92 Infiltration Equipment sensible load 32537 Btuh Method Simplified Latent Cooling Equipment Load Sizing Construction quality Tight Fireplaces 1 (Average) Structure 928 Btuh Ducts 916 Btuh Heating Cooling Central vent (0 cfm) 0 Btuh Area (ft 5426 5426 Equipment latent load 1843 Btuh Volume (ft 38910 38910 Air changes /hour 0.13 0.05 Equipment total load 34380 Btuh Equiv. AVF (cfm) 85 32 Req. total capacity at 0.70 SHR 3.9 ton Heating Equipment Summary Cooling Equipment Summary Make Make Trade Trade Model Cond GAMA ID Coil ARI ref no. Efficiency 80 AFUE Efficiency 0 SEER Heating input 0 Btuh Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 °F Total cooling 0 Btuh Actual air flow 1736 cfm Actual air flow 1736 cfm Air flow factor 0.025 cfm /Btuh Air flow factor 0.049 cfm /Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0.95 Printout certified by ACCA to meet all requirements of Manual J 8th Ed. wrr•igghtsc:ft,. Right - Suite® Universal 7.1.19 RSU11776 2013- Mar -08 13 4229 Act,, .. HOLESALE\DocumentsWeafn'cool loads AC11ONBEARHILL #26A rup Calc= MJ8 Orientation = SE Page 1 , Load Short Form Job: Date: MARCH 6,2013 SECOND FLOOR By: k Project Information For. Design Information Htg CIg Infiltration Outside db ( °F) 0 87 Method Simplified Inside db ( °F) 70 75 Construction quality Tight Design TD ( °F) 70 12 Fireplaces 1 (Average) Daily range - M Inside humidity ( %) 50 50 Moisture difference (gr /Ib) 51 24 HEATING EQUIPMENT COOLING EQUIPMENT Make n/a Make n/a Trade n/a Trade n/a Model n/a Cond n/a GAMA ID n/a Coil n/a ARI ref no. n/a Efficiency n/a Efficiency n/a Heating input Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 °F Total cooling 0 Btuh Actual air flow 0 cfm Actual air flow 0 cfm Air flow factor 0 cfm /Btuh Air flow factor 0 cfm /Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat n/a Load sensible heat ratio 0 ROOM NAME Area Htg load Clg load Htg AVF Clg AVF (ft (Btuh) (Btuh) (cfm) (cfm) MSTRBTH 96 1922 665 48 33 STUDIO 697 8674 4935 218 242 OFFICE 420 4344 3337 109 164 FINISHED STORAGE 339 4884 1819 123 89 SECOND FLOOR 1552 19823 10756 498 528 Other equip loads 0 0 Equip. @ 0.92 RSM 9895 Latent cooling 241 — TOTALS 1552 19823 10137 498 528 Printout certified byACCA to meet all requirements of Manual J 8th Ed. d wriyhi Ri ht- Suite® Universal 7.1.19 RSU11776 2013- Mar -08 13 :42:29 Ai J u r r n 9 HOLESALE1 DocumentsHeatn' coolloadsACTIONBEARHILL #26A -rup Calc =MJB Orientation = SE Page 5 FIRST FLOOR 1889 30580 23591 768 1158 Other equip loads 0 0 Equip. @ 0.92 RSM 21704 Latent cooling 1496 TOTALS 1889 30580 23200 768 1158 Printout certified byACCA to meet all requirements of Manual J 8th Ed. 1 ri 1�ls�rt' Right- Suite® Universal 7.1.19 RSU11776 2013-Mar-08 13134229 y .,,,_ w .CC ...I HOLESALE\DocumentsWearn'cool loadsWC11ON8EARHILL #26A.rup Calc= MJ8 Orientation = SE Page 4 ;., Load Short Form Job: Date: MARCH 6,2013 . k,a :,. , .,._, FIRST FLOOR By: Project information For. Design Information Htg CIg Infiltration Outside db ( °F) 0 87 Method Simplified Inside db ( °F) 70 75 Construction quality Tight Design TD ( °F) 70 12 Fireplaces 1 (Average) Daily range - M Inside humidity ( %) 50 50 Moisture difference (gr /Ib) 51 24 I HEATING EQUIPMENT COOLING EQUIPMENT Make n/a Make n/a Trade n/a Trade n/a Model n/a Cond n/a GAMA ID n/a Coil n/a ARI ref no. n/a Efficiency n/a Efficiency n/a Heating input Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 °F Total cooling 0 Btuh Actual air flow 0 cfm Actual air flow 0 cfm Air flow factor 0 cfm /Btuh Air flow factor 0 cfm /Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat n/a Load sensible heat ratio 0 ROOM NAME Area Htg load Clg load Htg AVF CIg AVF (ft (Btuh) (Btuh) (cfm) (cfm) MASTER 323 4413 2835 111 139 SUN 144 6265 4757 157 233 HALL 44 0 0 0 0 BATH 90 0 0 0 0 B E D2 180 3458 1423 87 70 LIV 252 59 2089 1 103 FOYER 107 1752 751 44 37 DINING 176 1969 1780 49 87 MUSIC 165 2772 1146 70 56 BREAK 108 5088 4456 128 219 KIT 180 1321 2794 33 137 LAUNDRY 120 3481 1559 87 77 Printout certified byACCA to meet all requirements of Manual J 8th Ed. 1 wc t g Ri ht- Suite® Universal 7.1.19 RSU11776 2013- Mar -08 13,4229 -..I HOLESALE1DocunentsWearn'cool IoadstAC11ONBEARHILL #26A.rup Calc= MJ8 Orientation = SE Page 3 Load Short Form Job: '- "` 4: ' °" ":' 4 r'r BASEMENT Bate: MARCH 6,2013 r• 1 Project Information For: Design Information Htg Clg Infiltration Outside db ( °F) 0 87 Method Simplified Inside db ( °F) 70 75 Construction quality Tight Design TD ( °F) 70 12 Fireplaces 1 (Average) Daily range - M Inside humidity ( %) 50 50 Moisture difference (gr /Ib) 51 24 HEATING EQUIPMENT COOLING EQUIPMENT Make n/a Make n/a Trade n/a Trade n/a Model n/a Cond n/a GAMA ID n/a Coil n/a ARI ref no. n/a Efficiency n/a Efficiency n/a Heating input Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 °F Total cooling 0 Btuh Actual air flow 0 cfm Actual air flow 0 cfm Air flow factor 0 cfm /Btuh Air flow factor 0 cfm /Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat n/a Load sensible heat ratio 0 ROOM NAME Area Htg load Clg load Htg AVF Clg AVF (ft (Btuh) (Btuh) (cfm) (cfm) CELLAR 1985 18724 5090 470 250 BASEMENT 1985 18724 5090 470 250 Other equip loads 0 0 Equip. @ 0.92 RSM 4683 Latent cooling 105 TOTALS 1985 18724 4788 470 250 Printout certified byACCA to meet all requirements of Manual J 8th Ed. ,. w ricc�l ' Iitc�rt' Right - Suite® Universal 7.1.19 RSU11776 2013- Mar -08 13:42:29 . cc I HOLESALE\Documents\Heatn'cool Ioads\AC11ONBEARHILL #26A.rup Calc= MJ8 Orientaton = SE Page 2 e.0,..A 4 2.0 Load Short Form Job: �' 1/4��c GOco,,v if a S { Date: MARCH 6,2013 D ,Je,, Entire House By: Project Information For Design Information Htg Clg Infiltration Outside db ( °F) 0 87 Method Simplified Inside db ( °F) 70 75 Construction quality Tight Design TD ( °F) 70 12 Fireplaces 1 (Average) Daily range - M Inside humidity ( %) 50 50 Moisture difference (gr /Ib) 51 24 HEATING EQUIPMENT COOLING EQUIPMENT Make Make Trade • Trade Model Cond GAMA ID Coil ARI ref no. Efficiency OAFUE Efficiency 0 SEER Heating input 0 Btuh Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 °F Total cooling 0 Btuh Actual air flow 1736 cfm Actual air flow 1736 cfm Air flow factor 0.025 cfm /Btuh Air flow factor 0.049 cfm /Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0.95 ROOM NAME Area Htg Toad Clg load HtgAVF CIgAVF (ft (Btuh) (Btuh) (cfm) (cfm) BASEMENT 1985 18724 5090 470 250 FIRST FLOOR 1889 30580 23591 768 1158 SECOND FLOOR 1552 19823 10756 498 528 Entire House 5426 69127 35366 1736 1736 Other equip loads 0 0 Equip. @ 0.92 RSM 32537 Latent cooling 1843 TOTALS 5426 69127 34380 1736 1736 Printout certified byACCA to meet all requirements of Manual J 8th Ed. wriyt>ttscsrt• Right -Suite Universal 7.1.19 RSU11776 2013- Mar - 0813 4229 _.I NHOLESALE \DocumentsWearn'cool loads \AC11ONBEARHILL #26A rup Calc= MJ8 Orientation = SE Page 1 _ ¥ 2 2= \ ® > m 0 « ' .' - \ . r« \o+ :: \ate � �� < m yy «z; \ «a \\ <rn I z , \ > \¢ \ \� 20 rn� ' 3m& \\ : » < « ' --I s $«�m / �d � /m (*I \\ ) ,713„, m -i \ x / 1!! \ C y r 0 { ® a « 2 \ » \ 2 m ¥ «r -TI ! \ ( I 2 » «« ® 2 \ g z \m q . @ $ ! s \ \: - M$,q �& « ' pd' ® ƒ «2\ ,:::',...'.1.1 4 o 4 , :d' « d 2\ »_ m w d }3 fri <7 , 0 , : .. 0 w» \ \ § I I ' 1�I �I, �r ,;A I i i , �[ I P a Cam 1 „Aril," Lt-t: N J _ k,:3: '1 e r n m1 i A 8 il 6 ' y am ` ' ; I $ li sal in' 1 g ,,.� r:-.1 o f 70 w & CO� _! � r ii i � ';` >' , r ACORD C ERTIFICATE OF LIABILITY INSURANCE DATE(MM / 2012 Y) TM 05/01 /2012 PRODUCER Phone: (413) 781.2410 Fax: 413 731 - 9539 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INSURANCE CENTER OF NEW ENGLAND INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1070 SUFFIELD STREET HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P 0 BOX 1230 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. AGAWAM MA 01001 INSURERS AFFORDING COVERAGE NAIC # INSURED ;INSURER A Central Insurance Company 20230 ACTION AIR INC !INSURER B. Commerce Insurance Company 34754 P.O. BOX 636 FEEDING HILLS MA 01030 INSURER C. 'INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS 11459 ACDI' TYPE OF INSURANCE - POLICY NUMBER ■ POLICY EFFECTIVE I POLICY EXPIRATION LIMITS I DATE IMM/DDANI DATE IMM/DOITY) I GENERAL LIABILITY CLP7978942 I 04/30/12 04/30/13 ; EACH OCCURRENCE I s 1,000,000 X ' COMMERCIAL GENERAL LIABILITY ; DAMAGE To RENTED $ 300,000 ' i -"'- i I i PREMISES (Es ocarenu I ) I CLAIMS MADE X ' . OCCUR ..... - - . -. MED EXP (Any one person) ($ 5,000 A PERSONAL 8 AOV INJURY :$ 1,000,000 • j • GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER - ' PRODUCTS - COMP /OP AGG $ 2,000,000 POLICY I. I ACT ! LOC AUTOMOBILE LIABILITY YM3030 04/30/12 04/30/13 COMBINED SINGLE LIMIT j ANY AUTO (Ea accident) $ 1,000,000 • ALL OWNED AUTOS ' BODILY INJURY X SCHEDULED AUTOS (Per person) g B X i HIRED AUTOS BODILY INJURY X NON -OWNED AUTOS I (Per accident) $ ( I I PROPERTY DAMAGE $ : (Per accident) GARAGE LIABILITY ' AUTO ONLY - EA ACCIDENT $ ANY AUTO - OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY CXS7978943 04/30/12 04/30/13 EACH OCCURRENCE ' S 2,000,000 X OCCUR CLAIMS MADE AGGREGATE $ 2,000,000 A i S DEDUCTIBLE $ RETENTION $ 0 s WORKERS COMPENSATION AND WC797894416 04/30/12 04/30/13 X Woav uM LIMITS OTHER 'EMPLOYERS' LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE - E L EACH ACCIDENT $ 500 000 OFFICER/MEMBER EXCLUDED? . - - E L DISEASE - EA EMPLOYEE $ 500,000 U yet, oeecrlbe Howl SPECIAL PROVISIONS below - E L DISEASE - POLICY LIMIT $ 500,000 OTHER: DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS TO SHOW EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE FOR VERIFICATION OF INSURANCE PURPOSES ONLY TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES AUTHORIZED REPRESENTATIVE • 1;1611 Attention: tephen Gallagher ACORD 25 (2001/08) Certificate # 62630 © ACORD CORPORATION 1988 The Commonwealth of Massachusetts to Department of Industrial Accidents t Office of Investigations ''� 600 Washington Street Boston, MA 02111 -�' a � www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legiblv Name (Business /Or anizatiortMdividual i`r_ .��..�.0 ...._.. B ) Address: P() &)( City /State /Zip: ■ ( Phone #: (1 S -- C OS Are you an employer? Chec the appropriate box: Type of project (required): 1. I am a employer with 1-9- 4. 0 I am a general contractor and I 6. t g131ew construction employees (full and/or part- time).* have hired the sub - contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub - contractors have 8. 0 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 3.0 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 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other — 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 contractor must submit a new affidavit indicating such. Contractor that check this box must attached an additional sheet showing the name of the sub- contractor and state whether or not those entities have employees. lithe 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: eP.11-4-A O-P , fl S ., /t a Cq_ a- et..A_ Policy # or Self -ins. Lic. #: WC f g C7 Lf `7 / L Expiration Date: V'ADI f Job Site Address:ca, Mail IC () ( &ni f D r City /State /Zip: `I` /pre e(_ , .2.4 $ 01 ° 1 0-) 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 or insurance cove verification. I do hereby certi u • er the • � ale of perj�hat the information provided above is true and correct � . � t = s :� �L �L Date: y s_ r Phone #: Y13 --2 `1 -7305 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 #: INSURANCE COVERAGE: 1 have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes o ❑ It 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 chocking this bo '4 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the bee .1 y knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with 11 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 r /27 By aster ) , / • -' r ; Tine ❑ Master - Restricted / ' ..., - City/Town ❑Journeyperson Signature of Licensee Permit* ❑Journeyperson - Restricted License Number 71 ( 1D Fee $ ❑ Check at www.mass.gov /dpl Inspector Signature of Permit Approval • File # SM- 2013 -0045 APPLICANT /CONTACT PERSON ACTION AIR ADDRESS/PHONE P 0 BOX 636 (413) 789 -9305 PROPERTY LOCATION 26 MARK WARNER DR - 20 BRIDGE RD MAP 16B PARCEL 001 026 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out /3 j 9 0d` 5 Fee Paid / Typeof Construction: HVAC SYSTEM R610i New Construction - �� Non Structural interior renovations Addition to Existing -I � �� 1J Accessory Structure Building Plans Included: Owner/ Statement or License 7110 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN 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 - t i • v : - Commi Permit DPW Storm Water Management 3 7 l /' Signature of Buil ing 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. CUti"i1r t^� l 1ct Sheet Meta ermit�� ~' �`J'�� t eta XY .. ^o,c 0\ OL Date: 3i1 \ Permit # 6M —/ 3 Estimated Job ost: f `• Permit Fe : $ ,�. 41 . N. Plans Submitted: YES NO Plans Reviewed: YES NO / N/ licant License # Business License # pP Business Information: Property Owner / Job Location Information: Name: Jn t — �`J�"C. Name: %..lC7L'QA -A �IAVIA ( - ), ,r° 1 Street:" O Street: o)l9 (y \a,f WoJC(v.( 1)/ V\t_ City/Tows: \ flS Iq O O City /Town: (V1A D I 0 \a' Telephone: \`3 -- - 9 - S0- Telephone: Li t 3 r QV( -- L}'Su 0 Photo I.D. required / Copy of Photo I.D. attached: YES NO Staff 'atlas! J -1 (M -1- unrestricted license J -2 / M -2- restricted to dwellings 3- stones 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. ft. ,) over 10,000 sq. ft, Number of Stories: Sheet metal work to be completed: New Work: Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney / Vents Air Balancing Provide detailed description of work to be done: 26 MARK WARNER DR - 20 BRIDGE RD SM- 2013 -0045 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON GIS #: 12146 O RtHAMpT O \. Map: 16B Block: 001 ,. � a SHEETMETAL PERMIT :Lot: 026 �� : Permit: SHEETMETAL TE RCENT P� ;Category: SHEETMETAL ( Permit # SM- 2013 -0045 PERMISSION IS HEREBY GRANTED TO: Project # JS- 2013- 001366 Est. Cost: $12,500.00 Contractor: License: Expires: '__ _..g ACTION AIR Sheetmetal - 7110 :Fee Fe_ Charged: : $25.00 06/28/2014 [Balance Due: $.00 Owner: 20 BRIDGE ROAD LLC j# of Fixtures: Applicant: ACTION AIR DigSafe # AT: 26 MARK WARNER DR - 20 BRIDGE RD UseGroup ConstClass li ISSUED ON: 12- Mar -2013 AMENDED ON: EXPIRES ON: TO PERFORM THE FOLLOWING WORK: HVAC SYSTEM - LINE DRAWING BEFORE ROUGH INSPECTION 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: Amount: Sheetmetal REC 2013 - 003877 11 Mar - 13 1319 $25.00 212 Main Street, Phone:(413) 587 -1240, Fax:(413) 587 -1272, Email :lhasbrouck @northamptonma.gov GeoTMS® 2013 Des Lauriers Municipal Solutions, Inc.