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24D-001
SM-2023-0027 253 PROSPECT ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24D-001-001 CITY OF NORTHAMPTON Permit: Sheet Metal PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# SM-2023-0027 PERMISSION IS HEREBY GRANTED TO: Project# SHEET METAL 2023 Contractor: License: Est. Cost: 16000 ALLSTATE HOOD &DUCT INC Const.Class: Exp.Date: Use Group: Owner: B'NAI ISRAEL CONGREGATIONAL Lot Size (sq.ft.) Zoning: URB Applicant: ALLSTATE HOOD &DUCT INC Applicant Address Phone: Insurance: 88 NOTRE DAME ST (413)568-4663 08WECAD8C9A WESTFIELD, MA 01085 ISSUED ON: 08/25/2023 TO PERFORM THE FOLLOWING WORK: HVAC KITCHEN HOOD POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: N{VOL, , tiPt Fees Paid: $112.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner //i 51,q1e horee / oa'c t Commonwealth of Massachusetts Sheet Metal Permit 2 Date: e/a(f/�'-) RECEIVED Permit# s In' A3'4 z Estimated Job Cost: $ /Cad J • - Permit Fee: $ 00)- eiii4(t(2i6 AUG 2 4. 2023 Plans Submitted: YES V N P ans eviewed: YES NO Business License# 723 DFPT.OF GULG*gat a�nI r�DINTON.�1�6ant Li ense# 25236 Business Information: Property Owner/Job Location IInnnformation:�' Name: Allstate Hood&Duct,Inc. Name: C,7 e /I �� ► -� ✓i-Ze f Street: 88 Notre Dame St. Street: f5 0j62.6. ST' City/Town: Westfield,MA 01085 City/Town: /1 lin-e Telephone: 413-568-4663 Telephone: Photo I.D. required/Copy of Photo I.D.attached: YES(X NO Staff Initial J-1 / -1 nrestricted 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 V Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System Ni Metal Chimney/ Vents Air Balancing Provide detailed description of work to be done: KITCHEN EXHAUST HOOD PER ATTACHED PLANS INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes�j No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy [J Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only / Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this boxL i,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 Inspections Date Comments Final Inspection Date Comments Type of License: By [17.1 Master Title ❑ Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: 25236 Fee$ ❑ Check at itutitL (1) g./ / a Inspector Signature of Permit Approval The Commonwealth of Massachusetts ► l Department of Industrial Accidents I Congress Street,Suite 100 1/4 _t_S = 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): Allstate Hood & Duct, Inc Address: 88 Notre Dame St. City/State/Zip: Westfield, MA 01085 Phone#: 413-568-4663 Are you an employer?Check the appropriate box: Type of project(required): 411 am a employer with 5 employees(full and/or part-time).* 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.El Electrical repairs or additions proprietors with no employees. 12.El Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 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. 14.0 Other Kitchen exhaust 152,I1(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 infonnation. 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: The Hartford — Policy#or Self-ins.Laic.#: 08WECAD$C9A Expiration Date: 1�/06/223 Job Site Address: oC f 3 T2rd S �7 City/State/Zip� C v,-t Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration on 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 y be arded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify nde is and penalties of perjury that the information provided above is true an correct Signature: — Date: ei7,2_,/ ,), Phone#: 7/> 'r6 T yL C 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#: ��'1 ALLSHOO-01 - ATKACZ '4 CC)Ro CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYVY) �-� 10/12/2022 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 TAME; Bearingstar Insurance,Inc. PHONE FAX 200 Friberg Parkway INC,E/A INo,Ext):(888)491-8466 1(NC,No):(508)366-4810 Suite 2006 ,ADDRESS: Westborough,MA 01581 INSURERS)AFFORDING COVERAGE NAJC# INSURER A:Twin City Fire Insurance Co 29459 INSURED INSURER B:Hartford Accident and Indemnity Company 22357 Allstate Hood&Duct,Inc- INSURER C:Hartford Ins Co of the Midwest 37478 88 Notre Dame St INSURER D: Westfield,MA 01085 INSURER E: INSURERF: 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 ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYI't (MM/DD/YYYYI LIMITS A COMMERCIAL GENERAL LABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR 08SBAAD7563 10/6/2022 10/6/2023 PAMAGE TO RENTED PREMISES(Ea occurreocel $ 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 JEI° LOC PRODUCTS-COMP/OPAGG S 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea acddentl $ X ANY AUTO 08UECBA5712 10/6/2022 10/6/2023 BODILY INJURY(Per person) S OWNED r--SCHEDULED AUTOS ONLY _ AUTOS BODILY INJURY(Per accident) $ AVTEEOS ONLY AUTOS o N p PROPERTY DAMAGE _ �Vy ONEY (Per actldent) S $ A UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS UAB CLAIMS-MADE 08SBAAD7563 10/6/2022 10/6/2023 AGGREGATE $ DED X RETENTIONS 10,000 S 2,000,000 C WORKERS COMPENSATION ' PER OTH- AND EMPLOYERS'LIABIUTY STATUTE ER _-- ANY PROPRIETOR/PARTNER/EXECUTIVE YIN O8WECAD9C9A 10/612022 10/6/2023 EL EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE$ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY OMIT $ DESCRIPTION OF OPERATIONS I 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. AUTHORIZED REPRESENTATIVE DocuSigned by: rhld / l 466CFC4927B04CB... ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD MASSACHUSETTS DRIVER'S LICENSE R 12/0112021 A°S61705244 .r ;v : j2I29I2026 ' 12129/1967 L,^tiCt'�155 12 REST 9a EAU D' NONE NONE 'ton- 2 TOUD WIWAM L`v' a 122 HILLSIDE RD APT 1 WESTFIELD,MA 01085.4106 1S BLU G 15 EX 5 DO 12'02/2621 Rev 021212011 12/29/67 0 COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE \\, tu MASTER—UNRESTRICTED \ TODD W DUVAL \ a ALLSTATE HOOD&DUCT .14 88 NOTRE DAME ST WESTFIELD,MA 01085 25236 12/28/2023 146042 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER 4 COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE BUSINESS cD TODD W DUVAL •N ALLSTATE HOOD&DUCT, INC. Z 24 MAINLINE DR WESTFIELD,MA 01085 723 01/07/2024 146098 L'ICENSEiNUMBER EXPIRATION DATE SERIAL NUMBER