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25C-018 (2) 180 - 182 NORTH ST SM-2020-0044 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON GIS#: 4405 Map: 25C Block: 018 SHEETM ETAL PERMIT Lot. 001 Permit: "SHEETMETAL Category: SHEETMETAL Permit# SM-2020-0044 PERMISSION IS HEREBY GRANTED TO: Project# jJS-2020-000681 Est.Cost: $6,000.00 Contractor: License: Expires: Fee Charged:!$25.00 ADVANCED MECHANICAL SERVSheetmetal-6360 10/28/2020 Balance Due:$.00 Owner: MARDAS PAULA #of Fixtures:: Applicant. ADVANCED MECHANICAL SERVICES DigSafe# AT. 180- 182 NORTH ST UseGroup ConstClass ISSUED ON. 19-Jun-2020 AMENDED ON. EXPIRES ON. TO PERFORM THE FOLLOWING WORK: INSTALL HEATING&AC 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-2020-003520 19-Jun-20 1291 $25.00 212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck@northamptonma.gov GeoTMS®2020 Des Lauriers Municipal Solutions,Inc. v Commonwealth of Massachusetts i � Z c co Sheet Metal Permit - o D N pate: '� G�0 Permit# �U Fqfim�Q Job Cost: $ 4 0 Permit Fee: $ rA tted: YES CCNO II II Plans Reviewed: YES NO Business License# g6-ap0)11 `T Applicant License#6; 3 6 r) e- toll -P/zo Business Information: r Property Owner/Job Location Information: Name:lyanyed Mechanl��l fcrV�d Name: Street:0 Pff Kfirn44M 5f Street: City/Town:ec elfa n, MA City/Town: Telephone: ��)3� C��� Telephone: 01-)) S_3,3 - 3q-13 Photo I.D.required/Copy of Photo I.D. attached: YES NO Staff initial J-1/M- -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: 2 Sheet metal work to be completed: New Work: Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System v Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: C7 111n\\s (3 JP�r�cc The Commonwealth of Massachusetts Department of IndusitialAccidents Office of Investigations 1 Congress Street,Suite 100 s<y Boston,MA 02114-2017 www mass gov/dw Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers App licant Information (" Please Print Leeibly Name (Business/Organization/Individual): Address: No Raeynnimat S� Ci /State/Zi ei'hunMAwbtl Phone#: Mo) 10 Ab6 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I ployees(full and/or part-time).* have hired the sub-contractors 6. ❑ ew construction 2. am a sole proprietor or partner- listed on the attached sheet. 7. remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9. Buildingaddition [No workers' comp.insurance comp.insurance.: ❑ required.] 5. ❑ We are a corporation and its 10.❑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 121-1 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑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 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 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.#: Expiration Date: Job Site Address: City/State/Zip: 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. i lure: Date: V Ile dor Phone# Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: INSURANCE COVERAGE: 1 have a current liability Insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 YesSj,'No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑,I hereby certify that all of the details and Information i have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and Installations performed under the permit Issued for this application will be In compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Profzress Inspections Date Comments Final Inspection Date Comments Type of License: By MrMaster Title ❑ Master-Restricted Cityrrown ❑Joumeyperson Signature of Licensee Permit# —�- ❑Joumeyperson-Restricted 3 6 License Number: Fee$ _ ❑ - Check at www.mass.gov/dpl 44__-- Inspector Signature of Permit Approval