32C-058 (13) 155 PLEASANT ST - FORMER 129 N'TON LODGE SM-2017-0060
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
GIS#: 10119 >e
Map: 32C
`k oo$ i a SHEETMETAL PERMIT
Permit SHEETMETAL
Category: demolition --
Permit u sM-zon-ooeo PERMISSION IS HEREBY GRANTED TO:
Project JS-2017-000249
Est.Cost: $170,000.00 Contractor: License: Expires:
Fee Charged:$50.00 -'KLEEBERG SHEET METAL INC Sheetmetal-2192 10/28/2015
__.
Balance Due:$.00 Owner: CHICOPEE KENDALL, LLC
of Fixtures:. !Applicant: KLEEBERG SHEET METAL INC
DigSafe# AT: 155 PLEASANT ST-FORMER 129NTON LODGE
UseGroup
ConstClass - -
ISSUED ON: 08-Jun-2017 AMENDED ON: EXPIRES ON:
TO PERFORM THE FOLLOWING WORK:
INSTALL NEW BATHROOM EXHAUST&RANGE HOOD EXHAUST FOR 70 RESIDENTIAL UNITS,COMPLETE
HVAC SYSTEM FOR COMMON AREAS, INCLUDING EXHAUST FAN,ROOF TOP UNIT AND ENTHALPY RECOVERY
UNIT
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-2017-006597 02-Jun-17 16574 85000
212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck@northamptoama.gov
GeoTMS®2017 Des Lauriers Municipal Solutions,Inc.
File#SM-2017-0060
APPLICANT/CONTACT PERSON KLEEBERG SHEET METAL INC
ADDRESS/PHONE 65 WESTOVER RD (413)589-1854 0
PROPERTY LOCATION 155 PLEASANT ST-FORMER 129 N'TON LODGE
MAP 32C PARCEL 058 001 ZONE CB(I00)/
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: INSTALL NEW BATHROOM EXHAUST&RANGE HOOD EXHAUST FOR 70
RESIDENTIAL UNITS,COMPLETE HVAC SYSTEM FOR COMMON AREAS, INCLUDING EXHAUST
FAN,ROOF TOP UNIT AND ENTHALPY RECOVERY UNIT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 2192 ,f
3 sets of Plans/Plot Plan gF,Fro/v,C I/a't-5
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
proved 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
'e min Elm Str-. o 'on Permit DPW Storm Water Management
Signature of Bui ding 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.
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Commonwealth of Massachusetts
City Of Northampton
�— mate: 5/30/17 Sheet Metal Permit Permit# Sm- i/ - (ip
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�3 Estimated Job Cost $ 170,000 Permit Fee: $ 50.00
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Plans Submitted: YES X NO Plans Reviewed: YES NO
!.Business License# 24 Applicant License# 2192
Business Information: Property Owner/Job Location Information:
Name: Kleeberg Sheet Metal Name: Live 155
Street: 65 Westover Road street 155 Pleasant Street
City/Town: Ludlow, Ma 01056 City/Town: Northampton, Ma 01060
Telephone: 413-589-1854 Telephone: (413)322-3077
Photo I.D. required/Copy of Photo I.D. attached: YES x NO
Staff Initial
J-1 ® estricted 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 x
Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. x Number of Stories: 4
Sheet metal work to be completed: New Work: Renovation:
HVAC x Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney/Vents Air Balancing
Provide detailed description of work to be done:
Install new bathroom exhaust and range hood exhaust for 70 residential units, install
complete HVAC system for common areas, including exhaust fan, roof top unit, and
enthalpy recovery unit.
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
f t
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 0 Bond 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee dreg not have the insurance coverage required by Chapter 112 of the
Massachusetts General Laws,and that my signature on this permit application wabresthis 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
pragract incpaetinu%
Late rnm.nents
Final Incpartion
Late rnmmentc
Type of License:
By ® Master
Title 0 Master-Restricted
I
City/Town ❑Joumeyperson
Signature of Licensee
Permit it
❑Joumeyperson-Restricted 2192
License Number:
Fee S
Check at annul macc gnu/dill
inspector Signature of Permit Approval
.,---"+e1 KLEESHE-01
A4,--
? CERTIFICATE OF LIABILITY INSURANCE D, M rY»T
0512412017
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFMRMAIIVELY 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 cerdMcate holder Is an ADDITIONAL INSURED,the poUcy(es)must have ADDITIONAL INSURED proviskrns or be endorsed.
K SUBROGATION IS WAIVED, subject 10 the terms and conditions of the policy,certain policies may require an endorsement A statement on
this certificate does not confer tights to the certificate holder in lieu of such endorsement(s).
PRODUCER ACT
Insurance Center of New England,Inc arm (800)2434134
1070 Suffield Street W SA: jet Ho7:(413)7319539
Agawam,MA 01001 'Moo _.....__.....
_ INSURERS __, 1,. .fCOVERAGE x •
. ..... i o suRERA:Repubik FrarihlM Maumee Company,
INSURED .IXSLURER e:UUca National Insurance Company
Newberg Sheet Metal Inc I WIRER p:Phllade!nhlal dernnlN Ins Co _....
Kleeberg Mechanical Services LLC
85 Westover Rd LmsRER.q:Travelers Property Casualty Company of AmerIce
Ludlow,MA 01056
INSURER?:
COVERAGE§ 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.
1LIRR TYPE Gr WSURMIDE W� PODGY NUMBER _.... PO EVi - UNITS1,00B,BBe
A I X_CCM RCML amends UNMAN EACHH OCCURRENCE
CUMtlar X OCCUR PIW3304 104/01/201] 0/018018 M5Etr ustice1 4 100,000
MED ET41A+r Pv�els^n 5,800
rerSONAL a Apt"INJURY 1,000,000
GEN.AGGREGATE Un MAPPLIES PER: oENERAI,AGOREGATP _ 2,000,000
1 1 POLICY Y , T !t!tux+ PRODUCTS-QQMP/OPiGG1 2,000,000
foTw6B
B AUTOMOBILE LABILITY SINGLE LIMITJIIIAQLRINAL 1,000,000
ANT AUTO wCry �B404Bt 104101120170410112018 oQILY niwnv_)Pa,ew.ml
NRUSaiLY X AUVLULED B(gILY INJURYPLs wMferk
Xn ear X M�Te I .7w°.rer.a E
_.....
C X uMeREUALMB ' occuR I NOCCURR NCE5,000,000
UCESS tun CLAMS-MACE EtN72577375 04701/2017 °4101J2018 RCEGATE 5,000,000
DED ' X RETENTIONS 10,000
H
B woman corsewisanom XiPER
0A
Acro EMROYERe'LMMMIY WI. ;,c.,,,,e` �04701801T 81M1801g 1,000,000
nRwWWyinXIR rELI PA(ECMVE r ('^""" EACH ACCIDENT .
FI Exau m d NIA 1,000,000
a dw,b Hr E.I�DI6EA6E-EAEMr.OYEE .. 1,000,000
NFT CF OPERATIONS belowEL A E-POLICY LIMIT
D ,Commercial Umbrella HHZUP31M281001TNF 110017 ONo/80 8 Excess UmbrNis 10,000,000
I I
nesove oN OF OPERM1O S/LOCATIONS/VEHICLES(ACORD NA.A4CbwNl RMUM S[MM,may M eatthM N mare Rice weirana
To show evidence economy.
CE'TT .ATE HOLDER C•.CE, ?ION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE For Verification of Insurance Purposes ACCORDANCE W1114LI
THE POLICY
PRO�NNSCE WILL BB DELIVERED N
AUTHORIZED REPRESENTATIVE
ACORD 251201&03) co 1988-2015 ACORD CORPORATION. All rights reserved,
The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ir
=Titan--e Office of Investigations
_ =Im'- 600 Washington Street
„.
mum=f Boston,MA 02111
a'n www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lenibly
Name(BusincssOrganlutionnndividual):_ Kleeberg Sheet Metal
Address: 65 Westover Rd.
City/State/Zip: Ludlow Ma. 01056 phone#: (413)589-1854
Are you an employer?Cheek the appropriate box: Type of project(required):
I.® I am a employer with 115 4. 0 I am a general contractor and I 6. []New construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet t 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9. 0 Building addition
[No workers' comp.insurance 5. 0 We are a corporation and its
10.0 Electrical repairs or additions
required.] officers have exercised their
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,$1(4),and we have no 12.0 Roof repairs
insurance required.]1 employees.[No workers'
13.E]Otho*
comp.insurance required.]
May applicant that checks.box el must also fill out the section below showing their workers'compensation policy information
Homeowners who submit this affidavit indicating they arc doing a0 work and then hire outside contiutors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional shat drawing the name of the sub-contractors and theiravrken'earn/4 policy infosmation.
lam on employer that is providing workers'compensation insurance for my employees. Below is the policy and joh site
information.
Insurance Company Name: Utica Mutual Insurance Company
Policy It or Self-ins.Lic.#: 4640054 Expiration Date: 4/1/2018
Sob Site Address: Live 155 155 Pleasant Street eityiStatetzip:Northamptop, Ma 01060
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 Me pains and penalties of perjury that the information provided above is true and correct
Signature: Date'
phone#; 413.589.1854
Official use only. Do not write in this area,in be completed by city or town offciaf
City or Town: Permit/License#
Issuing Authority(circle one):
, 1.Board of Health 2.Building Department 3.CitytTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
It
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 any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another 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 states 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 any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contacting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply subcontractor(s)name(s),address(es)and phone number(s)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. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any 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 permiillicense applications in any 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 must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would tike to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel.#6174274900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass.govldia
Please visit our web site at bttpl//wdwasess.go
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DANIEL J KLEES£RC `* i!
ALEESERG SHEET METAL INC {SMI
65 WESTOVER RD rest'`?sa
LUDLOW MA 01056
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SNEETMEtAL WORKERS I CONTROL 53 696565
ISSUES THE FOLLOWING LICENSE AS A
BUSINESS IMPORTANT
PAWL J KIEEBERS it your license is Post,damaged or destroyed;rs inaawrete:or
KLEESERG SHEET METAL INC - needs to be corrected,visit our web site at mass.gov/dpi for
66 WESTOVER READ insbucation la ensurethe Prober omnden a you Rarmwai
and
LUDLOW MA 01066 Application and any other correspondence.
This license iS subject to Massachusetts n itiatint or
regulations.Your license Is,
s a irty under
24 /70/2046 126722 assigned to any Person or en t d as careered by law and/ap chis
license on your Parson M posted..,•. regulations.