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31B-004 (17) VIE! _. it .. t_ VNFiEho CT 0051-4450 dI,;U 1223 a in un d i r s to ensur e Me w oor vnA Any A your Rem =.,gin ,I?V c ,rnc o T y person w wry r un ter I aft? of la NL her no on yon pemaj or fw r_d as" dmd by to and/or CORARArONWEAUTI-i OF MASSACHUSETTS Y $ ?.wy x ¢,x FioI�A�y' Y 5'4 . � k.rtHZw a RxxwFY #rte t` BOARD OF 2 SHEET METAL. WORKERS ISSUES THE FOLLOWING LICENSE AS A BUSINESS 2 Z THOMAS J MESSENGER NORTHEASTERN SHEET METAL CO INC w ODA 1 JM SHEET METAL MI~ �,,�„4 6 NIBLICK RD ENFIELD CT o6o82-4456 5�19 04/26/16 6s 4.✓d SFf'n- �Y zone A Ie_L dwnagm, or chs1myew is naoni nouds n-ectr, ow my ,-v we s,yc h Ns wsons to ensure the prop,m:e._I g of your Rwaval _ d an; her cc I c, Ns kEnse,is subyY to 4Awwhww4 Gugm I aA mi __ -, _ eg ,�i, ,or cano an my P07cr U rmnvo FS aqonl c ov S-00- I MASSACHUSETTS DRIVER'S LICENSE 9a END 4d NUMBER NONE 860331614 111P2 o' 3 DOB 08-2-5-11169 15 sa M HGT NE S�S�NGER `� OMAS J PEASE RD a ' 'LONGMEADOW,MA 01028.3111 � 5 DD 09.30-2013 Rev 07-152009 NORTH23 OP ID:AO DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 07/15/2015 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 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 NAME: Tracy Fillian Bouvier Insurance PHONE FAX 29 North Main Street 1AIC No_nt1:860_-232-44_91 ___ tac,No�_860-232-6637 West Hartford,CT 06107 E-MAIL Tina Gerard ADDRESS tflllian @binsurance.Com INSURER(S)AFFORDING COVERAGE _ N_A_I_C#_ INSURER A:Arbella Protection Insurance INSURED NorthEastern Sheet Metal INSURER B:Arbella Indemnity Company, Inc. - -- - - - - 6 Niblick Road INSURER C Enfield,CST 06082 INSURER D 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. IN SR ADDL SUBR POLICY EFF I POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY I (MMIDDIYYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 DAMAGE TO RENTED A �X •COMMERCIAL GENERAL LIABILITY 18500058666 04/15/2015 04/1512016 PREMIREMI SES jEa occurrence) $ 250,00 CLAIMS-MADE FXI OCCUR MED EXP(Any one person) - $ 10,00 PERSONAL 8 ADV INJURY 1,000,00 GENERAL AGGREGATE $ 2,000,00 GE_N L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $_- 2,000,00 POLICY X PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,00 Ea accident $ A X ANY AUTO 1020019056 ! 04/15/2015 04/15/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED _ AUTOS AUTOS BODILY INJURY(Per accident) $ _ NON-OWNED j PROPERTY DAMAGE HIRED AUTOS i_ AUTOS ! (PER ACCIDENT) $ _ - $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,00 A EXCESS LIAB CLAIMS-MADE 4600058667 04115/2015 04/15/2016[AGGREGATE $ 5,000,00 DED X RETENTION$ 10,000 1 $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY _ TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE /N 9122570414 04/15/2015 04/15/2016 E.L. ACH ACCIDENT $ 500,00 OFFICER/MEMBER EXCLUDED? NIA ---- ---------- ---" "-- ----- ----------- (Mandatory in NH) E.L DISEASE EA EMPLOYEE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ 500,00 A Arbella Protection I 8500058666 04/1512015 04/15/2016 I i � DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Re: Sheet Metal Permit Job Hubbard Hall @ Clark School CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CI of Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City P ACCORDANCE WITH THE POLICY PROVISIONS. Building Dept. Puchalski Municipal Building AUTHORIZED REPRESENTATIVE 212 Main Street Northampton,MA o ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations I Congress Street, Suite 100 r4 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Bus iness/Organization/individual): NorthEastern Sheet Metal Address:6 Niblick Rd. City/State/Zip: Enfield, CT., 06082 Phone #:860-265-3805 Are you an employer? Check the appropriate box: Type of project(required): 1.❑- I am a employer with 42 4. ❑ 1 am a general contractor and I 6. F-1 New construction employees (full and/or part-time).* have hired the sub-contractors 2.El 1 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. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.F-1 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 1.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] 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:Arbella Indemnity Policy# or Self-ins. Lic. #:9122570414 Expiration Date:04/15/2016 .lob Site Address: Hubbard Hall @ Clark School, 47 Round Hill Rd. City/State/Zip: Northampton , MA 01063 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for ins ance coverage verification. I do hereby certify under a pai and penalties of perjury that the information provided above is true and correct. 07/15/2015 Si nature: Date: Phone#:. 860-26 5 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes�rNo❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE IVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts Gene Law ,and that my signature on this permit application waive this requirement. Check One Only Owner ❑ Agent ❑ S' nature of Owner or Owner's Agent By checking this box❑,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO ProorPCC 1U RpCCtinnc Date comments Final incpertinn Die Cumments Type of License: By Master Title ❑ Master-Restricted h. City/Town ❑Journeyperson Signature of Licensee Permit# r ❑Journeyperson-Restricted License Number. Fee$ Check at www macs gnvlrtr Inspector Signature of Permit Approval Commonwealth of Massachusetts City Of Northampton aye Sheet Metal Permit Permit i Est` ated Job Cost: $ Permit Fee: $ P1 s Submitted: YES )< NO Plans Reviewed: YES NO - $u�iness License# Applicant License # 2--2---L? u mess Information: Property Owner/ Job Location Information: Name: i'S r � ,S} rw, I 1t\Vz,\� Name: i-6 klL C 019,4- l :SC..L411;I Street: Street: 4 r) K0'U City/Town: C T GG 0 2 City/Town: �3 '�►�c�a.,R I'1s� � (V1� Telephone: �, Z G���` � '�-s Telephone: ti Photo I.D. required/Copy of Photo I.D. attached: YES NO Staff Initial J-1 M-1- nrestricted 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: X HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: R'l 1.1 Got 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 File#SM-2016-0004 APPLICANT/CONTACT PERSON NORTHEASTERN SHEET METAL CO INC ADDRESS/PHONE 6 NIBLICK RD (860)265-3805() PROPERTY LOCATION 47 ROUND HILL RD-HUBBARD HALL MAP 3 1 B PARCEL 004 001 ZONE URC(l00)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE Fee Paid At Building Permit Filled out Iro Fee Paid Tvpeof Construction: ALL HVAC WORK FOR HUBBARD HALL New Construction Non Structural interior renovations Addition to Existing Accesso Structure Building Plans Included: Owner/Statement or License 519 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 -Perni4 from E1 Street Co ion Permit DPW Storm Water Management Signature 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. 47 ROUND HILL RD - HUBBARD HALL SM-2016-0004 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON �GIS#: 9474 Map: 31B Block:: 004 - -- - -- SHEETMETAL PERMIT ot: -- 001 Permit: SHEETMETAL Category: SHEETMETAL Permit# SM-2016-0004 PERMISSION IS HEREBY GRANTED TO Project# JS-2015-002314; Est. Cost: Contractor: License: Expires: Fee Charged:$50.00 NORTHEASTERN SHEET METAL Sheetmetal-519 04/26/2016 Balance Due:$.00 Owner: HISTORIC ROUND HILL SUMMITT #of Fixtures Applicant. NORTHEASTERN SHEET METAL CO INC DigSafe#` AT. 47 ROUND HILL RD-HUBBARD HALL UseGroup ConstClass ISSUED ON: 27-Jut-2015 AMENDED ON. EXPIRES ON. TO PERFORM THE FOLLOWING WORK: ALL HVAC WORK FOR HUBBARD HALL 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-2016-000316 22-Jul-15 29543 $50.00 212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck @northamptonma.gov GeoTMS®2015 Des Lauriers Municipal Solutions,Inc.