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23B-046 (279) 30 LOCUST ST SM-2020-0031 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON GIS#: 9098 Map: 23BBlocp � _ Lot: _ 046__ ________ � SHEETMETAL PERMIT Lot: _ o01 _ ,�,r,o.. .., Permit: SHEETMETAL Category: SHEETMETAL Permit# SM-2020-0031 PERMISSION IS HEREBY GRANTED TO: Project# JS-2020-001541 Est.Cost: $150,900.00 Contractor: License: Expires: Fee Charged:$50.00 NORTHEASTERN SHEET METAL Sheetmetal-519 04/26/2020 Balance Due:$.00 Owner: COOLEY DICKINSON HOSPITAL INC #of Fixtures: Applicant: NORTHEASTERN SHEET METAL CO INC DigSafe# AT: 30 LOCUST ST . UseGroup ConstClass ISSUED ON: 05-Mar-2020 AMENDED ON: EXPIRES ON.- TO N:TO PERFORM THE FOLLOWING WORK: HVAC 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 Shectmetal REC-2020-002794 04-Mar-20 35342 SO uU 212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck(a)northamptonma.gov GeoTMSCN 2020 Des Lauriers Municipal Solutions,Inc. E EIVED Commonwealth of Massachusetts ! MAR - 4 2020 City Of Northampton hj1,r INSPECTIONS Date: 2/28/20 Sheet Metal Permit Permit# Soo'ji-aB'= Estimated Job Cost: $_1 50,900 Permit Fee: $50.00 C�735342- Plans Submitted: YES X NO Plans Reviewed: YES NO Business License# 519 Applicant License # 2223 Business Information: Property Owner/Job Location Information: Name: NorthEastern Sheet Metal Name: Cooley Dickinson Hospital Street: 6 Niblick Rd. Street: 30 Locust St. City/Town: Enfield, CT 06082 City/Town: Northampton, MA 01060 Telephone. 860-265-3805 Telephone: 413-582-2000 Photo I.D. required/Copy of Photo I.D. attached: YES X NO Staff Initial J-1 /M-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 X Other Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. X Number of Stories: Sheet metal work to be completed: New Work: Renovation: X HVAC X Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: All HVAC sheet metal work for the Cooley Dickinson Hospital Childbrith Center renovation project per the contract drawings. 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, $100.00 Commercial INSURANCE COVERAGE: I have a current liabilitinsurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes❑ No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy K Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee dnpg not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waive this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Prnorpcc incnPrtionc Date Final incnPrtinn DaW ComimentS Type of License: By Master / MAP) Title ❑ Master-Restricted Thoma J. Messenger - President City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: Master-2223,Business 519 Fee$ ❑ Sheet Metal Business IfZ7 x Check at WWW mace env Inspector Signature of Permit Approval 1 0 ACORN CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) `—� 2/27/2020 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 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 CONTACT John M. Glover Agency PHONE Yesenia Maggio FAx P.O. Box 700 x, ).203-702-7924 203-672-4968 Norwalk CT 06852 EMAIL .ymaggio@johnmglover.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Standard Fire Insurance Company 19070 INSURED NORTSHE-02 INSURERB:The Charter Oak Fire Insurance Company 25615 Northeastern Sheet Metal Co., Inc. INSURER C:Phoenix Insurance Company 25623 6 Niblick Road Enfield CT 06082 INSURER D:Travelers Property Casualty Company of 25674 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1585570303 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 TYPE of INSURANCE ADOLSUOR POLICY EFF POLICY EXP LIMITS LTR IND WVD POLICY NUMBER MM/DD/YYYY MMIDD/YYYY C X COMMERCIAL GENERAL LIA131LITY 4T-CO-7K13408-7-PHX-19 4/15/2019 4/15/2020 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE XI OCCUR —PREMISES REMSES Ea occu encs $300,000 MED EXP(Any one person) $10,000 PERSONAL 8 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY 7 PRO- POLICY 7]LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: I $ B AUTOMOBILE LIABILITY 810-ON004640-19 4/15/2019 4/15/2020 COMBINED SINGLE LIMI I Ea accident $1,000,000 XANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY Per accident $ D X UMBRELLA LIAR X OCCUR N N CUP71<144462 4/15/2019 4/15/2020 EACH OCCURRENCE $5,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $5,000,000 DED I I RETENTION$ $ A WORKERS COMPENSATION N U87K104452 4/15/2019 4/15/2020 X I PER OT"- AND EMPLOYERS'LIABILITY STATUTE IN ER ANY PROPRIETOR/PARTNER/EXECUTIVE YN/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 C Equipment 4T-CO-7K13408-7-PHX-19 4/15/2019 4/15/2020 Leased/Rented 200,000 DESCRIPTION OF OPERATIONS/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. Proof of Insurance for Sheet Metal Permit. Job:Cooley Dickinson Hospital-Childbirth Center Renovation 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. Puchalski Municipal Building 212 Main St. Northampton MA 01060 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents IF Office of Investigations 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 39 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ 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.1 required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.EJ 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' 13.0 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: Standard Fire Insurance Company (a subsidiary of Traveler's Insurance) Policy#or Self-ins. Lic. #: UB7K104452 Expiration Date:04/15/2020 Job Site Address: Cooley Dickinson Hospital, 30 Locust St. 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 DI for insurance coverage verification. 77 Ido hereby certify nd t pains and penalties of perjury that the information provided above is true and correct. 2/28/20 Si pure: Dat e: Phone#: 860- 65-3805 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#: MASSAGHUSE TS DRIVERS LICENSE NOT FOR FrDERAL 0410412018 �. 2512023 6119 9uNn ' om NONE NONE El,SScNGI T i e Rf) ate. „ EA4T L0NGMr,M C" . 4� / :txaco�assk<vuzr22;xtU � � �� U# • a a BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE BUSINESS c THOMAS JMESSENGER ' NORTHEASTERN SHEET METAL CO INC yC4. �z DBA TJM SHEET METAL-MA 6 NIBLICK RD ENFIELD,CT 06082 6'19 0412612020 43429 • a COMMONWEALTH OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE MASTER-UNRESTRICTED THOMAS)MESSENGER 4; 1p 6 NIBLICK RD w ENFIELD,CT 06082-4456 � 2223 081261202/ 707975 ISI .x