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25A-185 (152) File#SM-2020-0008 APPLICANT/CONTACT PERSON KLEEBERG SHEET METAL INC ADDRESS/PHONE 65 WESTOVER RD (413)589-1854 Q PROPERTY LOCATION 45 INDUSTRIAL DR MAP 25A PARCEL 185 001 ZONE GI(101)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST E7CIOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid T3Teof Construction: INSTALL 2 NEW FANS&DUCT WO ERS AND GRILLES FOR NEW DRUM COOLER ROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 2192 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Permit from Elm Street Commission Permit DPW Storm Water Management L& J'T�� 10 � Si ature of BuildimgOfficial UO 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. *Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact the Office of Planning&Development for more information. Commonwealth of Massachusetts City Of Northampton (J Sheet Metal Permit a � Date: 9/25/19 E C E I V E D Pc rmit Estimated Job Cost: $ $25,000 SEP 2 6 2019 Pern it Fee: $ $50.00 Plans Submitted: YES X NO Plans 1evi wed: YES NO DEPT.OF BUILDING INSPECTIONS Business License# 24 NORTHAMP # 2192 Business Information: Property Owner/Job Location Information: Name: Kleeberg Sheet Metal Name: Coca-Cola Street: 65 Westover Rd. Street: 45 Industrial Drive City/Town: Ludlow, Ma 01056 City/Town: Northampton, MA 01060 Telephone: 413-547-8142 Telephone: (413) 586-8450 Photo I.D. required/Copy of Photo I.D. attached: YES X NO Staff Initial J-1 /(A .Inrestricted 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 X Educational Institutional Other Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. X Number of Stories: 1 Sheet metal work to be completed: New Work: X Renovation: HVAC X Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: Install 2 new fans and associated duct work, dampers and grilles for the new drum cooler room. Building Permit # BP-2020-0092 INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch.112 Yes(VNo ❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy L( 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 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 Progress Inspections Date Comments Final Inspection Date Comments Type of License: By [@ Master Title ❑Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: 2192 Fee$ ❑ Check at www.tnass.gov/dpf Inspector Signature of Permit Approval 45 INDUSTRIAL DR GIS p BP-2020-0092 MaCOMMONWEALTH OF MASSACHUSETTS Ma :Block: 25q _ 185 CITY OF NORTHAMPTON j. Lot: -00 P1 RSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Cate�orv: renovation BUILDING PERMIT I Perin it P BP-2020-0092 Project 4 JS-2020-000146 u Fst. Cost: $798000.00 I Fee: $5586.00 PERMISSION IS HEREBY GRANTED TO.- Const. Class: Contractor: , License: Use Group: R C STEVENS CO INC Licc Lot Size(sa. ft.): 948344 76 Owner: COCA COLA COMPANY THE ATTN: KYLE CARUTHERS 70111n2: G1001), Applicant: R C STEVENS CO INC AT.' 45 INDUSTRIAL DR Applicant Address' 28 S MAIN ST Phone: Iusuranc•e: WINTER GARDENFL34787 ISSL%ED ON: ( : X800 8/7/Z0190:0000 TO PERFORM THE FOLLOWING WORK:FLAMMABLE STORAGE ROOM- PHASED APPROVAL PENDING FIRE PROTECTION NARRATIVE E POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Rough: Rough: Footings: g House## Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke Final: MTHIS PERMIT MAY BE REVOKED BV THE CIT)' OF NORTHAMPTON UPON VI c ANY OF ITS RULES AND REGULATIONS. � VIOLATION OF Certificate of OccupancySignature: i FeeTvpe: Date P•iid• Amount [3uildi111 8/7/2019 0:00:00 $5536.00 ®wry■./4�.... syonm ....�,,.e..i ..,�"..k r,+x„•" r t ..4� 4 IAA -•.� • • f Vi, t r F Ln O r M + � ��t Yt1 �, • •i•��.`��yp IItIC Qa_ " ',.1....tY -gd .'.fid-".FAQ.• f, .i• 4 � � 'fitQr-k�� ``�1i.• *, . p 4 i 44 Fold,The,pew mmo �"All Perforations ow R 2 19z . IN ' r r /LC l.0//L//LV/L WCIILLII UJ lIY ILJJKI./I KJCLLJ Department of Industrial Accidents Office of Investigations 600 Washington Street .t` Boston, MA 02111 `"� S•v www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Kleeberg Sheet Metal Address: 65 Westover Rd. City/State/Zip: Ludlow Ma. 01056 Phone #: 413-547-8142 Are you an employer? Check the appropriate box: Type of project(required): 1.® I am a employer with 115 4. ❑ 1 am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 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. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 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.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.❑ Other 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. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Gallagher Bassett Policy#or Self-ins. Lic. #: WC0081102-00 Expiration Date: 4/1/20 Job Site Address: '%��'� �� +, / iT)r. N�,rl��7�iv A` City/State/Zip: 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 here under thepains and altie of perjury that the information provided above is true and correct. Si nature: Date: Phone#: 3 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 ('nntaet Pvrcnn• phnnv ft• KLEESHE-01 MPROULX CERTIFICATE OF LIABILITY INSURANCE DATE(M 3/22//201201YYY) 9 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 iELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED EPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy{les)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 CQNTACT NnRt Insurance Center of New England,Inc PHONE _ FAX ----- ------ 1070 Suffield Street INC,No,Ext) (800)243-8134 talc No)_(413)731-9539 Agawam,MA 01001 E MAlk APPR-SS ------- _.... INSURERS)AFFORDING_COVERAGE NAIC#_ ___ __._ ,tNSURERA RepubhcFranklminsuranceCompanY_._..._. :12475-------.-.-._. INSURED INSURERS Utica National InSUrance_COmpany _ — 10687____ KleebergSheet Metal Inc .INSURERc Philadelphia lndemnitylnCo18058 Kleeberg Mechanical Services LLC - -s_ --- - 65 Westover Rd INSURER D:Zurich American Insurance_Company ____ 1.6535 Ludlow,MA 0105& �— INSURER E Travelers Property Casualty Company of America 25674_ 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_. - - _.-._._. - -.......... -- - - ILT R TYPE OF INSURANCE ADDL SUER POLICY NUMBER' POLICY EFF POLICY EXP LIMITS R f / NYY : A X COMMERCIAL GENERAL LIABILITY 1 ' _EACH OCCURRENCE_ $ 1,000,000 CLAIMS-MADE X OCCUR I CPP4643304 411/2019 4/112020 REM SES aoccu_ nte) __-- 100,000 DAMAGE TO RENTED -------..___ ----.-_-_-•- E MEO EXP LAny one person) $_ S,OOO r - - --_—_-__ ------- PERSONAL`. PERSONALBADV INJURY $- 1,000000 - - GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY X JECT LOC I 2 000,000 __ I PRODUCTS COMPrOPAGG S____.__. - OTHER- COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY ��aacciden±l !..6..__._._..._...1,000,000 ANY aero I 4640484 4/1/2019 4/1/2020 BODILY INJURY LPerperson) $_ OWNED SCHEDULED AUTOS ONLY X_• AUTOS i _BODILY INJURY(PeracctlentJ �( ! HIRFbD X NON-QNMEO I i PROPERTY DAMAGE - -- --- - ; AUT S ONLY — AUTOa OONLY LPer accideng $.......... $ C X UMBRELLA LIAR OCCUR I EACH OCCURRENCE.. $ 5,000,000 EXCESS LIAB 1 - CLAIMS MADE; 'PHUB623693 4/1/2019 € 4/112020 .;,000,000 i._AGGREGATE .... -- --s----._.._ _...,. ..._.._ DED X RETENTION$ 10,000 $ D WORKERS COMPENSATION [ X :PER OTH AND EMPLOYERS'LIABILITY ._---- ANY PROPRIETORIPARTNERIEXECUTIVE YIN WC 0081102-01 3/1/2018 i 3/1/2020 1,000,000 OFFICERIMEMBER EXCLUDED . E L.EACH CCIDN $ in NH) N!a ------------------- (Mandatory 1,000,000 _E.L.DISEASE EA.EMPLOYEE. S__ ,,.•.,- _- It yes,describe under -- - -- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 E 'Commercial Umbrella ZUP31M2810018NF 4/1/2019 411/2020 Excess Umbrella 10,000,000 j DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES ACORD 101,Additional Remarks Schedule,may be attached if more space is required) To show evidence of coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Verification of Insurance Purposes Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD