31B-314 (4) The Commonwealth of Massachusetts
Department of Industrial Accidents
rid
W Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/OrgauizationMdividual): ' 1 ( OoC
Address:_
City/State/Zip.- �� ._ �,5 AL)phone #: �4 - t' _1 �6 _)
Are ou an employer?Check theme appropriate box: Type of project(required):
1.P1 am a employer with fJ 4• ❑ I am a general contractor and I
employees(fult and/or part-time).* have hired the sub-contractors G. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet, 7.
g.k:odeling
shi and have no em to ees These sub-contractors have 8. olition
working for me in any capacity. employees and have workers'
9. ❑Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑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.❑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 subcontractors 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:
Policy#or Self-ins. Lic.#:—Ah 4'', Expiration Date: 3c , _P
Job Site Address: � C ,�(t- �`-�U� City/State/Zip:__x>,r'�11
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c under the pa' d penalties perjury that the information provided above is true and correct
Siana, re. 4(:t Date: S l
Phone# �� Cj
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
INSURANCE COVERAGE:
I have a current liabili insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes#No❑
If you have checked Yes, indicate_ the t, , A coverage by -hecking th^appropriate box below:
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owrer's! r
By checking this box I hereby certify that alb of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best f my knowledge and that all sheet metal work ind installations performed under the permit issued for this application will be
in compliance with al pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
Duct Inspection required prior to insulation installation: YES NO
Progress Inspections
Date Comments
Final Inspection
Date Comments
Type of License,
By
kPaster
Title
❑ Master-Re stn cted
city/Town
❑Journeyperson
Signature of Licensee
Permit
Fee$ ❑Journeyperson-Restricted "7 11 C)
License Number:
O Check at www.mass.aovldal
Inspector Signature of Permit Approval
Sheet Metal Permit
Permit#
I f mated Job Cost: $ Permit Fee: $
o
di ° s Submitts=ti�. YES NO Plans Reviewed: YES NO
co �o �� 31�
N iness License# Applicant License# 3�
iness Information: Property Owner/Job Location Information:
_= & e: � u�l I°�l( ;�Y1('.. Name: �ftnw i y-; �k
Street: � uk h 3112 Street: l RIAL p/�y1U
City/Town, V-1 l It OWII' no( �O<Y�
r
Telephone:.4?�,--T�T�j � Telephone: ,�- � �� - D
Photo I.D. required/Copy of Photo I.D. attached: YES NO
_ --- Staff t.iri.l
J-1 kM-1-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
Square Footage: under 10,000 sq. ft. over 10,000 sq ft, Number of Stories:
Sheet metal work to be completed: New Work: Renovation: l\
HVAC Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney/ Vents Air Balancing
Provide detailed description of work to be done_
File#SM-2015-0044
APPLICANT/CONTACT PERSON ACTION AIR
ADDRESS/PHONE P O BOX 636 (413)789-9305
PROPERTY LOCATION 15 PARK AVE
MAP 3 1 B PARCEL 314 000 ZONE URC000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Tyneof Construction: INSTALL MINI SPLIT SYS(DUCTED REGISTERS,GRILLS,DIFFUSERS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildine Plans Included:
Owner/Statement or License 7110
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO MATION PRESENTED:
proved 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 Commission Permit DPW Storm Water Management
s-,�� /S
Sig e 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.
15 PARK AVE SM-2015-0044
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
GIs#: 11483
Map: 31B�
Block:- = aoo 314
Lot: - : , SHEETMETAL PERMIT
Permit: ~ SHEETMETAL
Category: SHEETMETAL.
Permit# SM-2015-0044 PERMISSION IS HEREB Y GRANTED TO:
Project# JS-2015-001577
Est. Cost: $1,500.00 1 Contractor., License: Expires:
Fee Charged:$50.00 ACTION AIR Sheetmetal- 7110 06/28/2016
Balance Due:$.00 Owner: MILLIKEN NANCY
#of Fixtures _T Applicant. ACTION AIR
DigSafe# _ _AT: 15 PARK AVE
UseGroup
ConstClass
ISSUED ON. 28-May-2015 AMENDED ON: EXPIRES ON.
TO PERFORM THE FOLLOWING WORK.•
INSTALL MINI SPLIT SYS(DUCTED REGISTERS,GRILLS,DIFFUSERS
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-2015-006435 28-May-15 2545 $50.00
212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck@northamptonma.gov
GeoTMS@ 2015 Des Lauriers Municipal Solutions,Inc.