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32C-047 (37) 110 P LEASANT ST SM-2020-0035 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON GIS#: 10109 Map: 32C Block: 04' SHEETMETAL PERMIT Lot: 001 Permit: SHEETMETAL ' Category: SHEETMETAL Permit# sM-2020-0035 PERMISSION IS HEREBY GRANTED TO: Project# IJS-2020-001403 Est.Cost: $9,000.00 Contractor: License: Expires: Fee Charged:i$50.00 CUSTOM SHEETMETAL CONSTRSheetmetal- 10290 10/28/2020 Balance Due:i$.00 Owner: RESINATE OF NORTHAMPTON #of Fixtures:; Applicant. CUSTOM SHEETMETAL CONSTRUCTION INC DigSafe# 1 AT: 110 PLEASANT ST UseGroup ConstClass ISSUED ON. 16-Mar-2020 AMENDED ON. EXPIRES ON. 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: Sheetmetal REC-2020-002886 16-Mar-20 10203 $50.00 212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck@northamptonma.gov GeoTMS®2020 Des Lauriers Municipal Solutions,Inc. 3dL�7 a � Commonwealth of Massachusetts City Of Northampton Date: 1 (012-D 2 Sheet Metal Permit Permit# 8A7; -ad- 35 Estimated Job Cost: $ q °° Permit Fee: $ J50 C�� 10 ZIP� Plans Submitted: YES NO Plans Reviewed: YES NO Business License# 10 2 R Applicant License# Business Information: Property Owner/Job Location Information: Name: (, �(, , I h G Name: Ees 1 h 10 L' Street: ,3 8 C e e, f2 e K H i I I 2d Street: J I o P S h t S+ City/Town: N- C;71-_-,i f 4Vn, MA City/Town: 4'0 h , MIA Telephone: lq,4 (p q 6 r7.6 r7 I Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES ✓ 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 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: HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: 1�� -t�021C x 5 ST 1N C, C'�- 5�./ STEM V6 Lb 1� Li _RU�vtA L0. oj- - l-,e_�k✓l. 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, $100.00 Commercial C*7 ` ' c� s fam Stege l�efa./7o Ivaw" � I INSURANCE COVERAGE: have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes❑ No ❑ If you have checked Yes, indicatte{the type of coverage by checking the appropriate box below: A liability insurance policy l<J Other type of indemnity r Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee rtnPs, not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waive this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this bo 10, hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO PrnarPcc Incnvrtinnc Final IncnPrtinn Date 1^nmmentc Type of License: By Master Title ❑ Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted '0 License Number: 1 02�- � x. �.o, Fee$ � � Check at WWW macs, govt 1 �0/, LV&� 3��c��ao Inspector Signature of Permit Approval The Commonwealth of Massachusetts = Department of Industrial Accidents a I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):Custom Sheetmetal Construction, Inc. Address:38 Creeper Hill Road City/State/Zip:North Grafton, MA 01536 Phone#:774-696-7571 Are you an employer?Check the appropriate box: Type of project(required): 1.[D I am a employer with 5 employees(full and/or part-time).* 7. ❑New construction 2.[]1 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.F1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 L]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.[:]Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions i.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ p Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14.❑Other 152,§1(4),and we have no employees.[No workers'comp,insurance required.] *Any applicant that checks box#I 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Associated Employer's Insurance Company Policy#or Self-ins.Lic.#:WCC50050119142019 Expiration Date:03/25/2020 Job Site Address:110 Pleasant Street City/State/Zip:North Hampton, MA Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby eer(ify wader the par sand penal{ies of perjury that the information provided above is true and correct. Signature: 0/ Date: <D Phone#:774-666-757/ 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 therContact Person: Phone#: ACORD' DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE rO3/02/2020 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 Larry Cowan Cowan Insurance Agency Inc. UHDNE978 3721451 FAX 978 521669 359 Main Street EMAIL larry@cowaninsurance.com INSURER(S)AFFORDING COVERAGE NAIC# Haverhill MA 01830 I R • Associated Employers Insurance Company INSURED INSURER B Kurt Partlow dba Custom Sheet Metal Construction INSURER C: 38 Creeper Hill Road INSURER D: INSURER North Grafton MA 01536 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. INSR TYPE OF INSURANCE DDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE �OCCUR DIR AMAGE.' RENTED MED EXP(Any oneperson) PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE POLICY PRO ❑LOC PRODUCTS-COMP/OP AGG JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMITE. $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY UMBRELLA UAB OCCUR EACH OCCURRENCE _4EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I T NTI N $ WORKERS COMPENSATION X I PERT"TF OTH- AND EMPLOYERS'LIABILITY FIR ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $100,000 A OFFICER/MEMBER EXCLUDED? FN N/A WCC50050119142019 03/25/2020 03/25/2021 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE_L100,000 If yes,describe under IDESCRIP I N OF OPERATIONS bel E.L.DISEASE-POLICY LIMIT $500 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Sheetmetal&HVAC contractor. Kurt Partlow owner of Custom Sheet Metal Construction is included on the Workers Compensation policy. CERTIFICATE HOLDER CANCELLATION Resinate,Inc SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 110 Pleasant Street ACCORDANCE WITH THE POLICY PROVISIONS. North Hampton,MA 01060 AUTHORIZED REPRESENTATIVE <SC> ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DATE(MM/DD/YYYY) ACOR" CERTIFICATE OF LIABILITY INSURANCE `,/ 1 3/3/2020 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 NAME: Karen BrDWrI _ Gaudette Insurance Agency, Inc. PHONE FAx 1 Plummers Corner (A/C,No,We 508-266-6453 ac No):508-234-8121 Whitinsville MA 01588 ADDRESS: kbrown@gaudette-insurance.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Hanover Insurance Company 22292 INSURED CUSTSHE-01 INSURER B:Allmerica Financial Benefit In 71840 Custom Sheetmetal Construction Inc 38 Creeper Hill Road INSURER C: N. Grafton MA 01536 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:696101689 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDD/YYYY MM/DD A X COMMERCIAL GENERAL LIABILITY ZHND57348801 5/1/2019 5/1/2020 EACH OCCURRENCE $1,000,000 DAMAGE TO R CLAIMS-MADE 1 X OCCUR PREMISES EaENTE occurrence $100,000 _ MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $2,000,000 JE O- LOC PRODUCTS-COMP/OP AGG $2,000,000 POLICY El _ OTHER: $ B AUTOMOBILE LIABILITY AWNH10886600 11/19/2019 11/19/2020 COMBINED SINGLE LIMIT $1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ _ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY YIN STATUTE OERTH ANYPROPRIETOR/PARTNER/EXECUTIVE N 1 A E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDEDT (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Resinate, Inc. 110 Pleasant Street North Hampton 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 SLIV 6/0 Lnamno»tia s�auwso .00',910H�t wx3s5t---- ma s3�a Z01,1ES1,0 VPS'N0lJVd9 HINON ad IIIH dld3380 9£ 2112InN 3NON 3NON ❑ �N3'. 1S3N t SSVI�" y �• 9166INO nozinlol ZS£6M8LES 6c0010z/so H39NIMI nt SSI 01 IVH3033 HO310N 3SN30Il s,�3nl�a S,L mf1mvSSylk, COMMONWEALTH OF MASSACHUSETTS 91 pi Rl Lei • • • •10 FA 0 11 MA il,6,15JR21IIIIIIIIII BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE W MASTER-UNRESTRICTED z z KURT R PARTLOW V) uj 38 CREEPER HILL RD NORTH GRAFTON, MA 01536-1422 '!4 z o 10290 10128/2020 588757 !° 0 .