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38B-006 (113) 126 WEST ST - CAMPUS POLICE SM-2020-0030 COMMONWEALTH OF MASSACHUSETTS -- CITY OF NORTHAMPTON GIS#: 10335 Map: 38B --------- - � },�� Block: 006 Lot: 001 - ,:w;` , SHEETMETAL PERMIT Permit: SHEETMETAL '' "a"' I � Category: SHEETMETAL Permit# SM-2020-0030 Project# ts-2020-001394 PERMISSION IS HEREBY GRANTED TO: Est.Cost: $13,400.00 Contractor: License: Expires: Fee Charged:$50.00 NORTHEASTERN SHEET METAL Sheetmetal-2223 08/28/2021 Balance Due:$.00 Owner: SMITH COLLEGE OFFICE OF TREASURER #of Fixtures: Applicant: NORTHEASTERN SHEET METAL CO INC DigSafe# AT: 126 WEST ST-CAMPUS POLICE UseGroup ConstClass ISSUED ON: 05-Mar-2020 AMENDED ON: EXPIRES ON: TO PERFORM THE FOLLOWING WORK.- HVAC ORK:HVAC THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND RtGULATIONS. Signature: Fee"Type: Receipt No: Date Paid: Check No: Amount: Sheetmetal REC-2020-002793 04-Mar-20 35340 $50.00 212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck(a�northamptonma.gov GeoTMS®2020 Des Lauriers Municipal Solutions,Inc. Commonwealth of Massachusetts RECEIVED City Of Northampton MAR - 4 2020 L Sheet Metal Permit r'"7 I ZPECTIONS Date: 2/28/20 Permit#QA"'`144 t0K 'a'i.n°oioso Estimated Job Cost: $ 13,400 Permit Fee: $50.00 Cj�lt 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: Smith College - Campus Police Street: 6 Niblick Rd. Street: 126 West St. City/Town: Enfield, CT 06082 City/Town: Northampton, MA 01063 Telephone: 860-265-3805 Telephone: 413-584-2700 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 X Institutional Other Square Footage: under 10,000 sq. ft. X over 10,000 sq. ft. 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 Smith Collge - Campus Police renovation project per the contract drawing. 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, $100.00 Commercial INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑■ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee dnp-z not haves the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waive this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box0,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO ProgressInspections, ]late Cnmmeuts Final incnPrtinn Vale Type of License: By ❑■ Master Zo/m' r./gM'11/eessenger Title ElMaster-Restricted Tha - President City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: Master-2223,Business 519 Fee$ ❑ Sheet Metal Business iy� x Check at WWW macs gr+_T Inspector Signature of Permit Approval The Commonwealth of Massachusetts Department of Industrial Accidents F Office of Investigations d 1 Congress Street, Suite 100 Boston,MA 02114-2017 ''M SV•�• 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): 1.0 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. EJ 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 g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: 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#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. #: U67K104452 Expiration Date:04/15/2020 Job Site Address: Smith College - Campus Police Station, 123 West 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 DIA/ r insurance coverage verification. Ido hereby certify u dethainsandpenallies of perjury that the information provided above is true and correct.2/28/20 Si afore: Date: 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#: 0 DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 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 NAME: Yesenia Maggio John M. Glover Agency PHONE203-702-7924 FAX 203-672-4968 P.O. BOX 700 (A/c,N Norwalk CT 06852 E-MAIL DRESS,ymaggio@johnmglover.com INSURERS AFFORDING COVERAGE NAIC N INSURER A:Standard Fire Insurance Company 19070 INSURED NOkTSHE-02 INSURER B:The Charter Oak Fire Insurance Company 25615 Northeastern Sheet Metal Co., Inc. INSURER c:Phoenix Insurance Company 25623 6 Niblick Road INSURERD:Travelers Property Casualty Company of 25674 Enfield CT 06082 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1787650559 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 POLICY EFF POLICY EXP LIMITS LTR INSD AND POLICY NUMBER MM/DD/YYYY MM/DD/YYYY C X COMMERCIAL GENERAL LIABILITY 4T-CO-7K13408-7-PHX-19 4/15/2019 4/15/2020 EACH OCCURRENCE $1,000,000 DAMAGE CLAIMS-MADE FX OCCUR PREMISES Ea occurrence $300,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY�JE7 LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: COMBINED SM151rTurr— $ B AUTOMOBILE LIABILITY 810-ON004640-19 4/15/2019 4/15/2020 Ea accident $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAG X AUTOS ONLY IX AUTOS ONLY Per accidentI $ $ D X UMBRELLA LIAB X OCCUR N N CUP71<144462 4/15/2019 4/15/2020 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED 1 1 RETENTION $ A WORKERS COMPENSATION N LIB71<104452 4/15/2019 4/15/2020 X I PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE YN/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? FY I (Mandatory In NH) E.L.DISEASE-EA EMPLOYEd$1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$1,000,000 C Equipment 4T-CO-7K13408-7-PHX-19 4/15/2019 4/15/2020 Leased/Rented 200,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The certificate holder is an additional insured under the general liability assumed under written contract with the insured executed prior to a loss. Proof of Insurance for Sheet Metal Permit Job: Smith College-Campus Police Renovations CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. Puchalski Municipal Building 212 Main St. Northampton MA 01060 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD MASSACHUSETTS bIN � NOT FOR FEDERAL K) 04/04#2018 ITO331614, - 112512023 06f3168 DM o ONE NONE' ..MESSENGER THOMASJ 88 PEASE RD EAST L€NGMEADOW,MA 01020.3111 etEx BLU f�v5 six M V-10" 08/2-5169 . / �' t)4t 8LY15flDt8 Rev Oy29/201$ LTH O i�A A z BOARD O SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE BUSINESS THOMAS J MESSENGER NORTHEASTERN SHEET METAL CO INC.C DBA TJM SHEET METAL-MA 6 NIBLICK ftp ENFIELD,CT 06082 , 519 0412612020 4342913 4 WARD OF— ty SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE a MASTER-UNRESTRICTED` P ,f THOMAS J MESSENGER f' 6 NIBLICK RIS ENFIELD,CT 06082-44,56 2223 081=2021 707978 y,