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38A-107 (6) 11 VILLAGE HILL RD SM-2019-0017 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON GIS#: X11835 Map: I38A Block: 107 SHEETMETAL PERMIT Lot: 001 Permit: SHEETMETAL Category: ISHEETMETAL (Permit# ISM-2019-0017 - -! PERMISSION IS HEREBY GRANTED TO.- Project# IJS-2019-000510 lst.Cost: ;$7,300.0_0 Contractor: License: Expires: Fee Charged:$50 00 NORTHEASTERN SHEET METAL Sheetmetal-519 04/26/2018 Balance Due:;$.00 iOwner: 11 VILLAGE HILL LLC #of Fixtures: ;Applicant: NORTHEASTERN SHEET METAL CO INC DigSafe# =AT: 11 VILLAGE HILL RD UseGroup L onstClass ISSUED ON: 27-Sep-2018 AMENDED ON: EXPIRES ON: TO PERFORM THE FOLLOWING WORK: all hvac duct systmes for the hampshire county sherifs office 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-2019-001088 26-Sep-18 33878 $50.00 212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck@northamptonma.gov GeoTMSOR 2018 Des Lauriers Municipal Solutions,Inc. INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes 0 No❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑■ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee dnpc nnf have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waive this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Prowess1n�nc Date Cnnimeuts Final ince Prfinn Dato Comments Type of License: By ❑■ Master �Q�t Title ❑ Master-Restricted Th ma J. essenger - President City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: Masters-2223,Business 519 Fee$ 0 SM Business Check at www macs g(v� idpi Inspector Signature of Permit Approval i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations W A d I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/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 45 4. ❑ I am a general contractor and 1 employees (full and/or part-time).* have hired the sub-contractors 6. E] 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 workingfor me in an capacity. employees and have workers' Y9. E] 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 11.❑ 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 41 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: Standard Fire Insurance Company (a subsidiary of Traveler's Insurance) Policy#or Self-ins. Lic. #: UB7K104452 Expiration Date:04/15/2019 Job Site Address: Hampshire Country Sheriffs Office, 11 Village Hill Rd. City/State/Zip: Northampton, 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 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 or in prance coverage verification. I do hereby Date: certify u ains and penalties of perjury that the information provided above is true and correct. Si nature: 1, 9/25/18 Phone#: 860-2 -3805 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#: i i DATE ACORV CERTIFICATE OF LIABILITY INSURANCE (MMIDD/YYYY) "ft , 1 9/24/2018 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: Penny Spinola John M. Glover Agency PHONE FAX P.O. Box 700 .203-956-2495 IALG No)c 203-274-9405 Norwalk CT 06852 E-MAIL ,pspinola@johnmglover.com INSURERS AFFORDING COVERAGE NAIC 0 INSURERA:Standard Fire Insurance Company 19070 INSURED NORTSHE-02 INSURER 13 She Charter Oak Fire Insurance Comp 25615 Northeastern Sheet Metal Co., Inc. INSURERC:Phoenix Insurance Company 25623 6 Niblick Road Enfield CT 06082 INSURER D:The Travelers Indemnity Company 25658 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 1281286655 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 ADDLSUBR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY C X COMMERCIAL GENERAL LIABILITY C07KI34087 4/15/2018 4/15/2019 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X I OCCUR DAMAGE Nc D PREMISES Ea occurrence $300,000 _ MED EXP(Any one person) $5,000 _ PERSONAL 8 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY a JECT M LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ OMINGLE LIMIT B AUTOMOBILE LIABILITY N BA6K925293 4/15/2018 4/15/2019 Ea accident $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ HIRED AUTOS XAUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X D X UMBRELLA LIAB X OCCUR N N CUP71<144462 4/15/2018 4/15/2019 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED RETENTION$ $ A WORKERS COMPENSATION N U1371<104452 4/15/2018 4/15/2019 X PER TH- AND EMPLOYERS'LIABILITY YIN STATUTE ER _ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? a NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000_ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The certificate holder is an additional insured under the general liability assumed under written contract with the insured executed prior to a loss. Job: Hampshire County Sheriffs Office Modifications Evidence of Insurance for Sheet Metal Permit CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. Pulaski Municipal Building 212 Main Street Northampton MA 01060 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD MASSACHUSETTS DRIVER'S LICENSE NOT FOR FEDERAL 10 �-"OdU2018 569331614 F0lt2512023 0$125/1969 CLASS REST EW DM NONE NONE MESSENGER THOMAS J 88 PEASE RD EAST LONGMEADOW,MA 61028.31 t t cyrs BLU I' Dn da umis Re blfa%,e 08/25/69 COMMONWEALTH OF MA SACHUSE S LY16*11010 gain - • • BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE BUSINESS THOMAS J MESSENGER NORTHEASTERN SHEET METAL CO INC C W DBA TJM SHEET METAL-MA 6 NIBLICK RD ENFIELD,CT 06082 519 04/26/2020 434290BOARD OF i SHEET METAL WORKERS ISSUES THE FOLLOWING:> MASTER-UNREST. THOMAS J MESSENGER 6 NIBLICK RD ENFIELD,CT 060824456 s fs { 2223 0191281x01971. 2868 `I t` North— Eastern E; Sheet Metal Co.,Inc. i 6 Niblick Road Enfield, CT 06082 Tel. (860)265-3805 Fax. (860)265-3815 RECEIVED To Whom It May Concern, SEP 2 6 2018 Please mail the Sheet Metal Permit to: oePr of surLDrNG iNSPecrioNs NORTHAMPTON,MA 01060 NorthEastern Sheet Metal Attn: Nick Fournier 6 Niblick Rd. Enfield, CT 06082 Of if you'd like to send a copy of the permit electronically, please email the permit tD: nfournier,nesmco.com Thank you, Nick Fournier General Manager NorthEastern Sheet Metal Co.,lnc.i� 6 Niblick Rd. Enfield, CT 06082 Phone: (860) 265-3805 Fax: (860) 265-3815 Email: nfournier@nesmco.com