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23B-046 (247) -MV q�r DRIVER'S LICENSE � 1 9a END 4d NUMBER NONE S60331614 -4 v' 3 DOB..... ,. 1 08-2 68 $ 15 BE% M -HGT O NE S5�NGER zTHOMASJ ' d a 88 PEASE RD i /� E LONGMEADOW,MA 01028.3111 5 DD 09.30.2013 Rev 07-15-2009 I r r `, r . r.ti 1799 LO a, , A c:1 Y G IIC',.'l61 u 0 PV P.Min a G I o ii :-f�'�.� ��(I i i. ..,C.03 !Once on ymv r` S( "I ,°posted as rrglAmd by sw andkr a«s sr y 'rte VlQNlMEA!.7-h ,.,E BOARD OF SHEET 'METAL 'WORKERS I SSUES THE FOLLOWING LICENSE AS A BUSINESS a iQ z THOMAS ,i MESSENGER NORTHEASTERN SHEET METAL CO INC .`hlu BEA iJM SHEET METPL - MA' 6 NIBLICK RD ENF I ELI) CT 06082-14456 l 519 04/20/ 16 197687 ,.�w- 0° k6 h• r, -6Cit -1.�3T n 6 _ L. __., _C(.5.rIras IR51 it ,oks to ensure We on 1 omTlo wr cj dim it F;Q,al u sp -U". , nsogned V an, NOW W=�'l V UnVY KnOty 0 I,-,,i Kew fhl vuno V7dlL�r The Commonwealth of Massachusetts ._�..�_...__..... Department of Industrial Accidents x � Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 S w�p www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): North Eastern 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. ❑ I am a general contractor and 1 employees (full and/or part-time).* have hired the sub-contractors 6. [] New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [] Remodeling ship and have no employees These sub-contractors have 8. [] Demolition working for me in any capacity. employees and have workers' 9. [] Building addition [No workers' comp. insurance comp. insurance.1 required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I l.[] 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 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. tContractors 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:4/15/16 Job Site Address: Cooley-Dickinson Hospital, 30 Locust St. City/State/Zip: Northampton, MA 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 i urance coverage verification. I do hereby certify and Xthens and penalties of perjury that the information provided above is true and correct. Si ature: Date:7/17/2015 Phone#: 860-2 -3 05 Official use only. Do not write in this area,to be completed by city or town gfficial. 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#: �---� NORTH23 OP ID: NK A�'ORL�►" DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 0711712015 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 Bouvier Insurance PHONE FAX 29 North Main Street A/c Ne Ex11:860-232-4491 hA/c,_No/ 860-232 6637 _ West Hartford,CT 06107 E-MAIL Tina Gerard ADDRESS:tfillian@binsurance.com INSURER(S)AFFORDING COVERAGE __ _ N_AIC# 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVQ POLICY NUMBER MMIDDIYYYY) [MM1DD/YYYY1 LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 _COMMERCIAL GENERAL LIABILITY 8500058666 04/15/2015 04/15/2016 DAMAGE TO RENTED A X _ PREMISES Ea occurrence $ 250,00 CLAIMS-MADE �• OCCUR MED EXP(Any one person) $ _ 10,00 PERSONAL&ADV INJURY $ 1,000,00 - i GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY X PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,00 _JEa accidents $ A X ANY AUTO 1020019056 04/15/2015 04/1512016 BODILY INJURY(Per person) S --------------- ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS _ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS _(PER ACCIDENT) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,00 A EXCESS LIAB CLAIMS-MADE 4600058667 04/15/2015 04/15/2016 AGGREGATE $ 5,000,00 DED X I RETENTION$ 10,000 $ WORKERS COMPENSATION X ORY IMITS O)T AND EMPLOYERS'LIABILITY --------- — B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 9122570414 04/15/2015 04/15/2016 E.L.EACH ACCIDENT $ 500,00 OFFICER/MEMBER EXCLUDED? ❑ N/A --- ------------"--"---- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 A Arbella Protection 8500058666 0411512015 04/15/2016 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Re: Evidence of Insurance for Sheet Metal Permit. Job: Cooley Dickinson Hospital - Emergency Department Renovation CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. Building Department Puchalski Municipal Building AUTHORIZED REPRESENTATIVE 212 Main Street Northhampton, MA 01060 � ,/X�u"-a ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD INSURANCE COVERAGE: I have a current liabilit 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 A Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee finpc not hay P the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waive 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 PrnarPCC TncpeCtionc Date Cents �,inal TnsnPZ ruin_ Date Comnelts Type of License: By f Master '2,7-1-3 Title ❑ Master-Restricted n City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted I'll?-3 License Number: 3 Fee$ SM B�r;r.vsr' S �q Check at www mace a�v�I Inspector Signature of Permit Approval Commonwealth of Massachusetts City Of Northampton � te: Sheet Metal Permit Permit#_ 6® � ��_ 0.5 c: , timated Job Cost: $ Permit Fee: $ Q � N C , i ns Submitted: YES NO Plans Reviewed: YES NO � a siness License# L °� Applicant License# siness Information: Property Owner/Job Location Information: ,p� � Go o�y Q i c,tc.;rso.• 1}o.s P' I-o.� Name: ILQ � IL Name: oP Street: Street: 3D I—o euS fi S�- City/Town: �f1�-_j R,W CGS City/Town: D r AA- a k Telephone: X 6 p Z6 -?8(2S Telephone: N A Photo I.D. required/Copy of Photo I.D. attached: YES >(- NO _ Staff Initial J-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. _X_ over 10,000 sq. ft. Number of Stories: 1 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: 1 k-r-1 P&&7TI o,. .H D_o,0& ia'.p li 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-2016-0005 APPLICANT/CONTACT PERSON NORTHEASTERN SHEET METAL CO INC ADDRESS/PHONE 6 NIBLICK RD (860)265-3805 Q PROPERTY LOCATION 30 LOCUST ST MAP 23B PARCEL 046 001 ZONE M(99)/WP(21)/URB(l) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: HVAC DUCTWORK FOR EMERGENCY ROOM New Construction Non Structural interior renovations Addition to Existin Accessory Structure Buildine Plans Included: Owner/Statement or License 519 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: Approved 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 P it from Elm Street Commission Permit DPW Storm Water Management Signature of Buildin f icial 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. 30 LOCUST ST SM-2016-0005 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON 0S#: 9098 Map:-- 23B Et iBl°ck: 046 �- SHEETMETAL PERMIT ILot: 001 Permit: SHEETMETAL Category: SHEETMETAL Permit# sM-2016-0005 PERMISSION IS HEREBY GRANTED TO: 'Project# JS-2015-001973 IEst.Cost: $14,400.00 Contractor: License: Expires: Fee Charged:$50.00 NORTHEASTERN SHEET METAL Sheetmetal-519 04/26/2016 iBalance Due:$.00 Owner: COOLEY DICKINSON HOSPITAL INC !#of Fixtures Applicant. NORTHEASTERN SHEET METAL CO INC DigSafe# AT. 30 LOCUST ST Use_Group ConstClass ISSUED ON. 27-Jul-2015 AMENDED ON. EXPIRES ON. TO PERFORM THE FOLLOWING WORK: HVAC DUCTWORK FOR EMERGENCY ROOM 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-2016-000317 22-Jul-15 29557 $50.00 212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck @n orthamptonma.gov GeoTMS©2015 Des Lauriers Municipal Solutions,Inc.