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12C-074 (2) SM-2023-0029 58 CAROLYN ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 12C-074-001 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-2023-0029 PERMISSION IS HEREBY GRANTED TO: Project# 2023 GAS APPLIANCES Contractor: License: Est.Cost: 3650 LIVINGSTONE HVAC Const.Class: Exp.Date: Use Group: Owner: KANE JOHN J Lot Size (sq.ft.) Zoning: RI/WSP Applicant: LIVINGSTONE HVAC Applicant Address Phone: Insurance: 91 BURLINGTON DR (413)335-9835 R2WC453518 AGAWAM, MA 01030 ISSUED ON: 10/26/2023 TO PERFORM THE FOLLOWING WORK: GAS FURNACE CHANGE OUT 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: I• y2 5)- # Fees Paid: $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner Commonwealth of Massachusetts City Of Northampton Date: f0 - a ' � Iermit Permit# Estimated Job Cost: $ -71 Lc Permit Fee: $ dfs a1 y OCT 244 Plans Submitted: YES NO 1 ?O23 Ian Reviewed: YES NO fFpT „ Business License# 6 _ ,rHA`;"NG INSP . ant icense # 60'S -?QN.t44 01(vio Business Information: Property wner/Job Location Information: Name: f';t`ri`n q 5 In"►e fk u ft C- Name: f iL%-5 1 Y,C.4 Q Street: 4 l eor l i � 1e14e- dr Street: C8 Ga, rol y K S City/Town: `-eed.l 'I� 141115 City/Town: 1 OCe N►Ce Telephone: Lit 3' 3 K.mot,$ 5S� Telephone: (4 ) 3 3 4 - 06 vo 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 'A Multi-family Condo /Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq.ft. jC over 10,000 sq.ft. Number of Stories: I. Sheet metal work to be completed: New Work: Renovation: K HVAC ,C Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: a S Fv r a (,t t,1no v►.9 i2 crs ' k.c.th v m >D vt✓\- fi \'erf Clbc i ;16 '' t� l6r2.0e 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, $100.00 Commercial INSURANCE COVERAGE: I have a current Jiahility insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes 7 No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy 71, Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee rinpa not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waivesthis requirement. Check One Only Owner K1 Agent ❑ Signature of Owner or Owner's Agent By checking this box❑,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO ProgrPcc incpeCtinns fate Comments Final incpeetinn fate Comments ) K/l /ram/7 Type of License: By ✓ 1 '��5 ❑ Master Title 40 - ' " ❑ Master-Restricted a. Sec �V °LK Ir; 5� Cityfrown ®Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted 60 '5 Jp.1-5/4/2-Al License Number: Fee$ ❑ Check at www mass gnv/rapt ///e Inspector Signature of Permit Approval ACC RU CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 10/24/23 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: Mike Pelletier Rejean J.Remillard Ins Agency, Inc. aoNN,Ext): 413-789-3070 FAX No): 413-895-5978 1040 Springfield Street E-MAIL Feeding Hills,MA 01030 ADDRESS: mikep@rejeanremillard.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: National Grange Mutual INSURED INSURER B: Amguard Insurance Co. Sergey Kulyak INSURER C: DBA Livingstone HVAC INSURER D 91 Burlington Drive Feeding Hills,MA 01030-2259 INSURER E: 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 ADDLBUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A Y Y MPT7588G 12/20/22 12/20/23 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 300,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A - OWNED SCHEDULED AUTOS ONLY AUTOS M1T9604L 11/18/23 11/18/24 BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ - EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER B OFFICER/MEMBERANY EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE YYN N/A R2WC453518 08/05/23 08/05/24 E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/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 TOWN OF NORTHAMPTON ACCORDANCE WITH THE POLICY PROVISIONS. 210 MAIN STREET - NORTHAMPTON ,MA 01060 AUTHORIZED REPRESENT .77 -- fi ©1988-2015 ACORD CORPORATION. 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