The URL can be used to link to this page

32A-162 (17) SM-2023-0016 33 HAWLEY ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 32A-162-001 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-2023-0016 PERMISSION IS HEREBY GRANTED TO: Project# 2023 RENO Contractor: License: ADAMS PLUMBING &HEATING Est. Cost: 1017837 INC Const.Class: Exp.Date: Use Group: Owner: NORTHAMPTON COMMUNITY ARTS TRUST INC Lot Size (sq.ft.) Zoning: CB Applicant: ADAMS PLUMBING &HEATING INC Applicant Address Phone: Insurance: PO BOX 126 (413)743-2308 ADAMS, MA 01220 ISSUED ON: 05/08/2023 TO PERFORM THE FOLLOWING WORK: HVAC 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: II ri r > ►l' Fees Paid: $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner Commonwealth of Massachusetts Sh e,tt tal Permit Date: VS/z / I/ELT- Permit # S�?�j --.2 / Estimated Job Cost: $ Ho -8 ae 7 P rmit Fee: $ o eig7 hcpT Plans Submitted: YES NO No°,nu,�ow PI Reviewed: YES NO _'=�x,roN INki 4 EcrioN Business License# 128 App" 'cant License# 3810 Business Information: Property Owner/Job Location Information: Name: Adams Plumbing & Heating, Inc. Name: vkl4tU-/1'10 ��'}1(t I1*14 T(U4t" Street: 43 Printworks Dr. (P.O. Box 126) Street: 5,6 Heuuteli c\-rze / City/Town: Adams City/Town: 10 k..16Lnup lfjh Telephone: 413-743-2308 Telephone: Photo I.D. required /Copy of Photo I.D. attached: YES X NO Staff Initial J-1 /M-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 7 Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: Renovation: f HVAC / Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Ven, Air Balancing ✓ Temp Heating/Cooling Louvers: Grease Ducts: FD&FSD: Provide detailed description of work to be done: 4e W duo- s ys51C,ffrbS for scc toil , V *. xn I Leah J1- id ou,Y-$ i Le cur j Vi duz,t'n y iou,V.t 4 j rigOted , l�d a.n� ne��k'oris * n4_wrJpmtk7t fur G. 7 c acid S etr.s . 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 ❑X 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 boxN, 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 Progress Inspections Date Comments Final Inspection Date Comments Type of License: By ® Master Title ❑ Master-Restricted e. City/Town Jeffr E��aignault ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: 3810 Fee$ ❑ Check at www.mass.gov/dpl 'hitt..),L <5) S/eb Inspector Signature of Permit Approval . The Commonwealth of Massachusetts 1 Department of Industrial Accidents 1 Congress Street, Suite 100 i" Boston, MA 02114-2017 ,,";A www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual):Adams Plumbing & Heating, Inc. Address:PO Box 126, 43 Printworks Drive City/State/Zip:Adams, MA 01220 Phone #:413i-743-2308 Are you an employer?Check the appropriate box: Type of project(required): I.�✓ I am a employer with 80 employees(full and/or part-time).* 7. ❑ New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. 0 Demolition 10 ❑ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.2Plumbing 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.: 6.1=I We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑✓ Other HVAC 152,§I(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 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-con ractors 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 Nye policy and job site information. Insurance Company Name:Massachusetts Employers Insurance Co., Inc. Policy#or Self-ins.Lic. #:MCC-200-2000025-2023A Expiration Date: 1/1/2024 Job Site Address:33 Hawley Street City/State/Zip: Northampton MA01060 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 v olation 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 verification. I do hereby certify under the pains and( penalties of perjury that the information provided above is true and correct. Signature: .r.r X/(!h t'.4.4_, Date: <5/51-Z3 Phone#:413-743-2308 0 Official use only. Do not write in this area,to be completed by city or tow*official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4.Ele trical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: • WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Massachusetts Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 58713 POLICY NO. MCC-200-2000025-2023A PRIOR NO. MCC-200-2000025-2022A ITEM 1. The Insured: Adams Plumbing & Heating Inc. DBA: Mailing address: P O Box 126 FEIN:**-***2575 Adams, MA 01220-0000 Legal Entity Type: Corporation Other workplaces not shown above: See Location 2. The policy period is from 01/01/2023 to 01/01/2024 12:01 a.m. standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 000124512 INTER 911837307 SEE CLASS CODE SCHEDU_E Minimum Premium $416 Total Estimated Annual Premium $126,667 GOV GOV Deposit Premium $13,347 STATE CLASS MA 5183 State Assessments/Surcharges $162,739.00 x 4.1800% $6,802 This policy, including all endorsements, is hereby countersigned by ' " - 12/07/2022 Authorized‘nature Date Service Office: MountainOne Insurance Agency Inc 330 Whitney Avenue 85 Main Street, Suite 100 Holyoke MA 01040 2789 North Adams, MA 01247 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. p� ADAMPLU-01 KOBRIEN ACO/�CP DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 1 211 5/2 0 2 2 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 POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Kathleen M O'Brien NAME: MountainOne Insurance Agency,Inc. PHONE FAX 85 Main Street,Suite 100 (A/C No,Eat):(413)663-2319 7138I(NC,No):(413)664-4723 North Adams,MA 01247 ADDRESS:kathleen.obrien@mountainone.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Mutual Insurance Company 17000 INSURED INSURER B:Arbella Protection Insurance 41360 Adams Plumbing&Heating Inc INSURER C:Massachusetts Employers Ins Co PO Box 126 INSURER D: Adams,MA 01220 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS _LTR INSD WVD IMM/DD/YYYYI (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 8500072452 12/31/2022 12/31/2023 DAMAGE TO RENTED 300,000 PREMISES(Ea Occurrence) $ MED EXP(Any one person) $ 15,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X ' LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: JOB SITE POLLUT $ 1,000,000 B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO 1020112824 12/31/2022 12/31/2023 BODILY INJURY(Per person) $ OWNED SCHEDULED _ AUTOS ONLY _ AUTOS BODILY INJURY(Per accident) $ HIRED NON WNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 EXCESS LIAB CLAIMS-MADE 4620113600 12/31/2022 12/31/2023 AGGREGATE $ 10,000,000 DED X RETENTION$ 10,000 $ C WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N MCC-200-2000025-2023A 1/1/2023 1/1/2024 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes.describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Equipment Floater 8500072452 12/31/2022 12/31/2023 A Installation/Build 8500072452 12/31/2022 12/31/2023 Any One Location 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityof Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. Dept.of Building Inspections 212 Main Street Northampton,MA 01060 AUTHORIZED REPRESENTATIVE ,s5/a4L-Eixzik dAth„1/4......_ ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD