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23B-046 (2) 30 LOCUST ST SM-2021-0046 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON GIS# ''9098 Map: 23B 4 t. Block: 1046 Lot: 001 � SHEETMETAL PERMIT Permit: 1SHEETMETAL Category: (SHEETMETAL Permit# sM-2021-0046 PERMISSION IS HEREBY GRANTED TO: Project# 1JS-2021-001578 License: Est.Cost: $9,270.00 Contractor: Expires: Fee Charged:$50.00 NORTHEASTERN SHEET METAL Sheetmetal-2223 08/28/2021 Balance Due:$.00 Owner: COOLEY DICKINSON HOSPITAL INC #of Fixtures: Applicant: NORTHEASTERN SHEET METAL CO INC .. DigSafe# AT: 30 LOCUST ST UseGroup ConstClass ISSUED ON: 08-Jun-202I AMENDED ON: EXPIRES ON: TO PERFORM THE FOLLOWING WORK: HVAC FOR MRI THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signat r : Fee Type: Receipt No: Date Paid: Check No: Amount: Sheetmetal REC-2021-003838 07-Jun-21 36290 $50.00 212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck@northamptonma.gov GeoTMS®2021 Des Lauriers Municipal Solutions,Inc. Commonwealth of Ma ss c uset�,a h /`�G �� c\j City Of Northampton 6/3/21 Sheet Metal Permit ti91�o;✓� ?°' 1,:v) Date: Permit# _/do Estimated Job Cost: $ 9,270 Permit Fee: $ ' ;'_ 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 I Commercial: Office Retail Industrial Educational Institutional X Other Square Footage: under 10,000 sq. ft. X over 10,000 sq. ft. Number of Stories: 1 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 MRI replacement renovation project per the contract drawings. *Drawings were emailed to the building department* 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, $100.00 Commercial 4 • INSURANCE COVERAGE: I have a current Jiahility insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes 0 No❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee rinPc not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application WaivPsthis requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box.,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Progrecc Increetinnq Date Cornmonts Final Incpeetinn Jute f ommonts Type of License: By El Master CPR,W, Title ❑ Master-Restricted Thoma . Messenger - President City/Town ❑Journeyperson Signature of Licensee Permit# c/� ❑Journeyperson-Restricted Master-2223,Business 519 Fee$ J V m 3c!Z 1' License Number: Sheet Metal Business x Q `� Check at www macs dnv/rlpl 10 �/U �" i/ Inspector Signature of Permit Approval The Commonwealth of Massachusetts Department of Industrial Accidents I1 'l Office of Investigations Mie lel A� I 1 Congress Street, Suite 100 I,�t Boston,MA 02114-2017 .:a..� wwwmass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeEibly 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): 1.171 I am a employer with 40 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. n Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' p n 9. 0 Building addition [No workers' comp. insurance comp. insurance.: 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 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 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 Ls providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Republic-Franklin Insurance Company Policy#or Self-ins. Lic.#:5438940 Expiration Date:4/15/2022 Job Site Address: Cooley Dickinson Hospital, 30 Locust St. City/State/Zip:Northampton, MA 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 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 r in urance coverage verification. /do hereby certify der h pains and penalties of perjury that the information provided above is true and correct Signature: / fpA4't Date:6/3/2021 Phone#: 860-2 5-3805 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#: DATE(MM/DD/YYYY) AccRD® CERTIFICATE OF LIABILITY INSURANCE 5/13/2021 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 (A/c.No.Extl:203-702-7924 (A/c,No):203-672-4968 Norwalk CT 06852 ADDRess: Ymaggio©johnmglover.com INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:Republic-Franklin Insurance Company 12475 INSURED NORTSHE-02 INSURER B:Utica Mutual Insurance Company 25976 Northeastern Sheet Metal Co., Inc. 6 Niblick Road INSURER C: Enfield CT 06082 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1984874014 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 INSD WVD, POLICY NUMBER (MM/DD/YYYY),(MMIDDIYYYY) A X COMMERCIAL GENERAL UABILITY 5448253 4/15/2021 4/15/2022 EACH OCCURRENCE $1,000,000 DAMAGE TO CLAIMS-MADE X OCCUR PREMISES(EaENTED 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 X POLICY JECOT- LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY 5437470 4/15/2021 4/15/2022 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ - OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) $ B X UMBRELLA LIAB OCCUR 5448254 4/15/2021 4/15/2022 EACH OCCURRENCE $5,000,000 - EXCESS LIAR CLAIMS-MADE AGGREGATE $5,000,000 DED RETENTION$ $ A WORKERS COMPENSATION N 5438940 4/15/2021 4/15/2022 X AND EMPLOYERS'LIABILITY STATUTE ERA ANYPROPRIETOR/PARTNER/EXECUTIVE Y� N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED7 (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 A Equipment N N 5448253 4/15/2021 4/15/2022 Leased/Rented 200,000 DESCRIPTION OF OPERATIONS I 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. Evidence of Insurance for Sheet Metal Permit. Job: Cooley Dickinson Hospital—MRI Replacement CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. Building Department Puchalski Municipal Building 212 Main Street AUTHORIZED REPRESENTATIVE Northampton, MA 01060 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD MASSACHUSETTS DRIVE I N8E NOT FOR FEDERAL ID I58 NUMBER 04104/2018 S00331614 08 125120023 08125/1969 S REST DM NONE NONE fi MESSENGER THOMAS J 88 PEASE RD EAST LONGMEADOW,MA 01028.3111 _ EYES BLU SEX M NGT 5'-W ,DO 04105/2018 Rev0Y7L101 08/.25/69 COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE :•• -• • SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSEtc MASTER-UNRESTRICTED a THOMAS J MESSENGER 6 NIBLICK RD ENFIELD,CT 06082-4456 2223 08/28/2021 707975 1>R41x1-4170firfl>II■I14:4 121it7,mr_TINNIIPT:TI1wl,ICrl:T1:1 OMMONWEALTH OF MA SACHUSETTS DIVISION OF PROFESSIONAL LICENSURE BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE LU BUSINESS cc THOMAS J MESSENGER NORTHEASTERN SHEET METAL CO IN CT to DBA TJM SHEET METAL-MA 6 NIBLICK RD ENFIELD,CT 06082 519 04/26/2022 883030 LICENSE NUMBER EX'I`A ION DATE SERIA NUMBER