18D-026 (75) 55 DAMON RD - UNIT 1A - HOT HEADS SM-2019-0044
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
GIs c.: _. 8933 _
Map: 18D
Block: 026 SHEETMETAL PERMIT
Lot; 001
Permit SHELL METAL
(Category: renovation i
—.
1Pertnd 9 sM0019-01134 Projectk JS-2019-001357 PERMISSION IS HEREBY GRANTED TO:
!Est. Cost: $11,000.00 Contractor: License: Expires:
Fee Charged:550.00 -ALLSTATE HOOD&DUCT INC SHEETMETAL BUSINESS-723 01/072020
Baleuc(Due .S.00 lOwner. AMERICAN DREAM REALTY
dFhamaa: _ _ .Applicant: ALLSTATE HOOD&DUCT INC
k AT., 55 DAMON RD-UNIT IA-HOTHEADS
CoDalClass
ISSUED ON. 27-Mar-2019 AMENDED ON: EXPIRES ON:
TO PERFORM THE FOLLOWING WORK:
kitchen exhaust hood
THIS PERMIT MAY BE REVOKED BY THIS CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: Dare P.Id: Chock No: Amount:
Sheeuneml REC-2019.003041 25-Mer-19 5173 $50.00
212 Main Street,Pho.c:(413)597-1241,Fae:(413)5874272.Email:Ihubruuek@norlhampmonu.em'
6euTMSX 2019 D.La..itn Municipal Solutions.Inc.
I
File#SM-2019-0044
APPLICANT/CONTACT PERSON ALLSTATE HOOD&DUCT INC
ADDRESS/PHONE 24 MAINLINE DR (413)56&4663
PROPERTY LOCATION 55 DAMON RD-UNIT IA-HOT HEADS
MAP 18D PARCEL 026 001 ZONE GIf 100
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
CLOSED REQUIRED DATE
ZONINGFORM FILLED OUT
Fee Paid
Buildin2 Permit Filled out
Fee Paid
Typeof Construction: kitchen exhaust hood
New Construction
Non Structural interior renovations
Addition to Existinc
Accessory Structure
Building Plans Included:
Owner/Statement or License 723
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved _Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER: §
Intermediate Project: Sim Pian 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
j!-✓'^-vc 420Signature of Building Official Dam
Now: 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.
Commonwealth of Massachusetts
City Of Northampton
10�ain
/9 Sheet Metal Permit Permit#
Clc+�(9✓
Cost:$ Jv0 - — PermitFee: $ SVd: YES NO Plans Reviewed: YES NO
se# 7a,3 Applicant License#
5norma//tion: Property Own/er. //Jobb Location Information:
'i���SF. b 1 1 Name: /,b� A/v0 /a'i^•k s
Street: a2y ✓�1yl4rn�-r Street:
City/Town: i,.I.JX.rCityfrown:
Telephone: 3-SL P• 5/G L 3 Telephone: qt3-dd I -0J'9 ?
Photo I.D. required/Copy of Photo I.D.attached: YES—Z NO_
srnrwrr
J-1 restricted 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 V
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 dd .Ption of work to be done:�
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,$100.00 Commercial
c a - i. \.
INSURANCE COVERAGE:
I have a current Bablligr insurance policy or its equivalent which meats the requirements of M.G.L.Ch.112 Yes No❑
N you have checked Yes,indicate the type of coverage by checking the appropriate box below:
A liability Insurance policy B Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee AN,not have the insurance coverage required by Chapter 112 of the
Massachusetts General Laws,and that m signature on this permit applicatlonnWlresthis requirement.
/ Check One Only
Owner ❑ Agent
Signature or Owner or Owners Agent
By checking this box1l,l hereby certify that all of the details and information I have submitted(or entered)regarding this appliwgon are true and
accurate to the beat of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will W
in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
Duct inspection required prior to insulation installation: YES NO
Prnwornc=lny�nrfin
DaW COm rntc
Fleet Ingpnrt'n
Date rnm cntc
Type License:
By Master
Inde ❑Master-Reshicted
City/rows OJoumeyperson
Signature of Licensee
permit s /
❑Joumeyperson-Restricted a3lO
License Number: ate$
Fee E �
Check at www m .. g tip idpi
Impactor Signature of permit Approval
AC-C>R& CERTIFICATE OF LIABILITY INSURANCE BD1
0`122M
DMB
r THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES
BELOW. THIS CERTIFICATE OF INSURANCE DOES HOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORED
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER
SAPORTANT: N Me cerlineale Nobler Is an ADDITIONAL INSURED,Me pollcy(les)must have ADDITIONAL INSURED provisions or be endomed.
K SIIBROGATON IS WAIVED,subject to Me berms and condi8ons of the policy,cerlam ,ollcles may require an endorsement A sMement on
Mia certificate does not confer H hbe W Me cereMcam holder in Iieu of such endomemen s.
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241vlaliine Drive Rahatt: HARTFORD NSCOOFTHEMIDWEST 37478
Westfield MA 01085
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CERTIFICATE HOLDER CNOEILATDN
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. THE PRAl1011 DATE THEREOF,
IgIMM WAL BE aF11VERED
29 Maelire Drive ADcgIDN1eE WI1H TH POl10YPR0YNOMS
Needed,MA MM
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01988-2015 ACORD COOKMTOK AM riBMs reelryed
ACORD 25)2016/09) The ACORD name and logo are registered marks of ACORD
�\ The Commonwealth of Massachusetts
Department of Industrial Accidents
J Congress Street,Suite 100
Boston,MA 01174-20777
www.massgov/dia
R corkers'Compensation Insurance Affidavit:Bu0ders/Contractors/Electricians/Plumbers.
10 BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Informationtae P nt Legibly
Name(Business/Olganizedonfldividae0:
Address: a�
r
City/State/Zip: I Djdyl'hone#: .>'-SLY'yG.�
Are ym an employer.CIMS the appraprlaa baa: Type of project(required):
II am a employer with employees(full anemic pun-time).• 7. []New construction
2 lamawlepmp mrorpaamrshipandh wwcmployeeswoddng fmmein g. ❑Remodeling
any capacity.iNo waders com,insurance mis uird.l
3.❑1 am a homeowner&.1.11 work myself[No waders'coni announce requirestj 9. ❑Demolition
4.[]l an a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition
mance that an contractors either have warlerscon,amostion nesurnmeemr am sale 11.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑1 am n gene.[comtutor and 1 have hired to sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-conwcmrs have employees and have w«kas'rooup.wsumnce.:
6.❑We areacoryoration and its am..have exemised their righter canni im per MGL.. 14.❑Other
152,§I(4),and we love no employaa,[No workescomp.insmvae requird.]
*Any applicam that checks box al must also fill ora the section below w
showing their aders wnrymiution policy infom itio a.
s Homeowners who submit this afidavit indicating they are doing all wad and then hire outside contractors most submit a new andion indicating such.
:Contractors that check this box must ams lied an additions]sheet showing the warn,of the sub-conrmctors and one,whether or not those entities have
employees. Ifthe mbconhnma.hove employees,racy must provide Meir waders'comp.policy.orad..
I am an employer that is providing workers'cam .sad incur rrfe for my employees Below is Poe policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: 0 0 L04E e 70/-1j-J Expiration Date: / r
Job Site Address- Izjp /—)lrel City/State/Zip: /U r, /h, -0
Attach a copy of the workers'compensation policy declaration page(showdng the policy number and ea§(iration date).
Failure to secure coverage as requited under MGL c. 152,§25A is a criminal violation punishable by a line 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 e
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cosify��under thepains traditional erjmy that the information provided above is one and correct
Signature: Date
Phone#
Official use only. Do not write in this area,to be completed by city or town ojjiciaf
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Clty/Towa Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
,,
_. ,_. Y� _
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 my contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or my two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or"at=of an individual,partnership,association or other legal entity,employing employees. However the
owner of dwelling house having not mom than three apartments and who resides therein,or the occupant of the
dwelling house of mother 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 slates 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 my of its political subdivisions shall
enter into my 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 In yew situation and,if
necessary,supply sub-contmcrnr(s)morels),addresses)and phone numbers)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. Alan be sure to sign and date the affidavit. The affidavit should
be returned m the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have my 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 my 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 most be filled out each
year. Where a home owner or citizen is obtaining a hccnw or permit not related to my business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and has number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I 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.gi vildia
ALLSTATE HOOD
24 MAINLINE DRIVE
WESTFIELD,MA 01085
OFFICE:413-568-4663
FAX:413.568-4665
DATE:
To Whom it May Concern, // e
I,Todd Duval,am allowing Ce,; 14 5c—"�A To use my license,to
pull a permit for the new hood system going into -focated at:
Please call with any questions or conc s.
Thank Y
Todd Duval
��rS ? '
D
LICENSE lo!
l�
d 2612016
129
'a,i F yp
Q.COMMONWEALTH OF MASSACHUSETTS
• • ' •
SOARD OF
SHEET METAL WORKERS
ISSUES THE FOLLOWING LICENSE 1
BUSINESS A•
TODD W DUVAL Il
ALLSTATE HOOD&DUCT,INC,
24 MAINLINE DR
WESTFIELD,MA OfOSS
723 01/0712020.
414780
v COMMONWEALTH OF MASSACHUSETTS
BOARD OF
SHEET METALWORKERS
ISSUESTHE FOLLOWING LICENSE j
MASTER-UNRESTRICTED Nth'
TODD W E VAL
HOO
ALLSTATE HOOD B.DUCT �
24 MAINLINE OR
WESTFIELD,MA olo85
25236 12/28/2014 488804 ;,
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