39A-039 (2) 33 HOCKANUM RD - WWTP SM-2021-0034
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
GIS#: 110455
Map: '39A }` ' '1
Look: 009 _ _ . �� ' SHEETMETAL PERMIT
Permit. 'SHEETMETAL rRccetcr+n�
Category: SHEETMETAL
Permit 1sM-2o21-o03a PERMISSION IS HEREBY GRANTED TO:
Project# JS-2021-000499
Est.Cost: $54,973.00 Contractor: License: Expires:
Fee Charged:$0.00 ADAMS PLUMBING&HEATING ISheetmetal-3810 07/28/2020
Balance Due:$.00 Owner: NORTHAMPTON CITY OF SEWERAGE TREATMENT PLANT CITY HA
#of Fixtures: Applicant: ADAMS PLUMBING&HEATING INC
DigSafe# AT: 33 HOCKANUM RD-WWTP
UseGroup
ConstClass
ISSUED ON: 23-Mar-2021 AMENDED ON: EXPIRES ON:
TO PERFORM THE FOLLOWING WORK:
HVAC &AIR BALANCING FOR RENOVATION
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON IO TION OF
ANY OF ITS RULES AND REGULATIONS. I 10 1
i • , • -
Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Sheetmetal REC-202 1-002807 18-Mar-21 NA $0.00
212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck a northamptonma.gov
GeoTMS®2021 Des Lauriers Municipal Solutions,Inc.
RECEIVE .) .�
Commonwealth of Massachusetts MAR 1 8 2021
City Of Northampton `
�� ,T �;
SUJI I;Cd� iS O710NS
Date: 3/12/2021 Sheet Metal Permit Permit# %"- - h°
Estimated Job Cost: $ 54,973.00 Permit Fee: $ N/
Plans Submitted: YES x NO Plans Reviewed: YES NO
Business License# 128 Applicant License # 3810
Business Information: Property Owner/ Job Location Information:
Name: Adams Plumbing & Heating, Inc. Name: Northampton WWTP
Street: 43 Printworks Drive Street: 33 Hockanum Road
City/Town: Adams, MA 01220 City/Town: Northampton, MA 01060
Telephone: 413-743-2308 Telephone: 413-587-1091
Photo I.D. required/ Copy of Photo I.D. attached: YES y 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 X - Wastewater Treatment Plant
Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. V Number of Stories: 3
Sheet metal work to be completed: New Work: Renovation: X
HVAC X Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney/Vents Air Balancing X
Provide detailed description of work to be done:
Headworks - New ERV and ductwork
Control Building - New RTU with VAVs installed in existing ductwork, ducted exhaust fans
Blower Building - New ducted fan coil unit
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:
. ..ave a current Jiahility insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes CI 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 tint have the insurance coverage required by Chapter 112 of the
Massachusetts General Laws, and that my signature on this permit application waivesthis requirement.
Check One Only
Owner El Agent ❑
Signature of Owner or Owner's Agent
By checking this box❑t,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 tncpectionc
Date Comments
Final Incpertinn
Date Cnrmnenfs
Type of License: ,l
By ❑� Master
Title ❑ Master-Restricted \ktir
City/Town Jeffrey . Daigna Signature of Licensee
Permit# ❑Journeyperson-Restricted 3810
License Number:
Check at www macc gnv/clpt
OV).J1
I Spector Signature of Permit Approval
l ,
Commonwealth of Massachusetts Commonwealth of Massachusetts
Division of Professional Licensure it Department of Fire Services
fy BU-026385
PipefiitteI /11testti d Master
si Oil Burner Technician Certificate
PMU-000353 expires:07/03/2022 h Y
JEFFREY E DAIGNAULT;
1 ASHFORD HGTS JEFFREY E DAIGNAULT
ADAMS MA 01220 1 AASHFORD HGHTS
i' ADAMS MA 01220
t-, F'''
a n,. � - - Expiration Date
State Fire Marshal 07/03/2021
Commissioner -:; a>�rt /`1. c.�Zr1r?;��a,.,
Commonwealth of Massachusetts I Commonwealth of Massachusetts
Division of Professional Licensure Division of Professional Licensure
Board of Building Regulations and Standards
SprinNe ,d ritr�ctor Cons rrttt r# iipfrvisor
5C-001368 tittpires: 07/03/2021 CS-021742 � E Spires: 07/03/2021
JEFFREY E DAIGNAULT / JEFFREY E DAIGNAULT ,,;
1 ASHFORD HGTS ;^; 1 ASHFORD HGTS
ADAMS MA 01220 r" ADAMS MA 01220
E
Commissioner Commissioner t<w c ^`'
v COMMONWEALTH OF MASSACHOS
4 f3:W ISi ..4 URE •iA MON Ai ...w._.. Y $ ,i...:...:.. CH 44
BOARD OF
DIVISION OF PROFESSIONAL LICENSURE
SHEET METAL WORKERS 3 BOARD O''
ISSUES THE FOLLOWING LICENSE SHEET'IVIETAI WORKERS
BUSINESS ISSUES THE E FOLLOWING LICENSE
MASTER-UNRESTRICTED a
JEFFREY E DAIGNAULT a
ADAMS PLUMBING AND HEATING INC JEFFREY E DAIGNAULT u
65 PRINTWORKS DRIVE I
PO BOX 126 t
ADAMS,MA 01220 ADAMS PE MBG AND HTG \ z
ADAMS,MA 01220-0128
128 11/2612022 963247 3810 07/28/2022 872959
;•ENSE NUMBER EXPIRATION DATE SERIAL N Via„ ,a-
UCENSE NUMBER EXPIRATION DATE SERIAL NUMBER.
The Commonwealth of Massachusetts
_.......- ¢ _ Department of Industrial Accidents
ffil
Mr 11 1 Congress Street,Suite 100
auto
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/lndividual):Adams Plumbing & Heating, Inc.
Address:PO Box 126,43 Printworks Drive
City/State/Zip:Adams, MA 01220 Phone #:413-743-2308
Are you an employer?Check the appropriate box: Type of project(required):
I I am a employer with 80 employees(full and/or part-time).* 7. ❑New construction
2❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
ally capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ❑ Building addition
4.❑1 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.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6 We are a corporation and its officers have exercised their right of exemption per MGL c.
14.❑✓ Other HVAC
152,§1(4),and we have no employees.[No workers'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: Massachusetts Employers Insurance Co., Inc.
Policy#or Self-ins. Lie.#:MCC-200-2000025-2021A Expiration Date: 1/1/2022
Job Site Address:33 Hockanum Rd City/State/Zip:NorthamptonMA 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 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.
I do hereby certify under the
�pains
�and penalties of perjury that the information provided above is true and correct.
Signature: VNtt'w4, Date: L-5/t 7/M f
Phone#:413-743-23
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.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Massachusetts Employers Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 58713
POLICY NO. MCC-200-2000025-2021 A
PRIOR NO. MCC-200-2000025-2020A
ITEM
1. The Insured: Adams Plumbing & Heating Inc.
DBA:
Mailing address: P O Box 126 FEIN:"-"`2575
Adams, MA 01220-0000
Legal Entity Type: Corporation
Other workplaces not shown above: See Location
2. The policy period is from 01/01/2021 to 01/01/2022 12:01 a.m. standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident
Bodily Injury by Disease $ 1,000,000 policy limit
Bodily Injury by Disease $ 1,000,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 000124512
INTER 911837307 SEE CLASS CODE SCHEDU_E
Minimum Premium $420 Total Estimated Annual Premium $122,123
GOV GOV Deposit Premium $12,762
STATE CLASS
MA 5183 State Assessments/Surcharges
$156,777.00 x 3.5100% $5,503
This policy, including all endorsements, is hereby countersigned by 12/14/2020
Authorized Signature Date
Service Office: MountainOne Insurance Agency Inc
330 Whitney Avenue 85 Main Street, Suite 100
Holyoke MA 01040 2789 North Adams, MA 01247
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
Adams Plumbing&Heating,Inc.
Ptint«orks L)tive,P.O.Bo 126 Transmittal Cover Sheet
Adams, MA 01220
Lic. #9052 Detailed, Grouped by Each Transmittal Number
Northampton WWTP Upgrades Project# 2020-18
#S-13258/001 Tel: Fax:
33 Hockanum Road
Northampton, MA 01060
Date: 3/17/2021 Reference Number: 0002
Transmitted To Transmitted By
Jonathan Flagg Kristin Wells
City Of Northampton Adams Plumbing& Heating, Inc.
212 Main Street PO Box 126
Room 100 Adams, MA 01220
Northampton, MA 01060 Tel: 413-743-2308
Tel: 587-1338 Fax:413-743-7350
Fax:
Acknowledgement Required
Package Transmitted .z.: .., h.." � K Tracking Number
Approval UPS
Item# Qty Item rapt ,. M. Status
0001 1.00 SM Permit Application
0002 1.00 WC Affidavit
0003 1.00 Plans
Remarks g�::a "•�7 k u �x x `. '�, a ` ,r' Tais
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Signature Signed Date
Prolog Manager Printed on: 3/17/2021 AdamsPlumbing Page 1