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31B-004 SM-2023-0031 46 ROUND HILL RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31B-004-001 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-2023-0031 PERMISSION IS HEREBY GRANTED TO: 2023 48 ROUND HILL RD Project# COOLIDGE HALL RENO Contractor: License: NORTHEASTERN SHEET METAL CO Est.Cost: 168200 INC Const.Class: Exp.Date: Use Group: Owner: LLC 1924 Lot Size(sq.ft.) Zoning: URC Applicant: NORTHEASTERN SHEET METAL CO INC Applicant Address Phone: Insurance: 6 NIBLICK RD (860)265-3805 CPP5448253 ENFIELD, CT 06082 ISSUED ON: 11/03/2023 TO PERFORM THE FOLLOWING WORK: HVAC FOR APARTMENTS 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: ,131/7/ Fees Paid: $50.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner C mmonwealth of Massachusetts NC - 1 2023 City Of Northampton 10/20& cT�ONs 5� Sheet Metal Permit Date: ,',,,, Permit# Estimated Job Cost: $ 1 68,200 Permit Fee: $50.00 372 3 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: Coolidge Apartments Street: 6 Niblick Rd. street: 48 Round Hill Rd. City/Town: Enfield, CT 06082 City/Town: Northampton, MA Telephone: 860-265-3805 Telephone: N/A 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 Commercial: Office Retail Industrial Educational Institutional Other X * 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: 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 Coolidge Apartments renovation project per the accompanying drawings. * 4 stories includes attic and basment. 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, $100.00 Commercial INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes No❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑■ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee rtnpc not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waivesthis requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Progress In'pections Date f nmmf-nts Final increetinri Date Comments z Type of License: -� By ❑■ Master Title ❑ Master Restricted Thom. J. Messenger - President City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted Master-2223,Business 519 License Number: Fee$ ❑ Sheet Metal Business Check at www macs rgnv/dpI 11/2/d3 In pector Signature of Permit Approval The Commonwealth of Massachusetts Department of Industrial Accidents )1 i-ir 1_ Office of Investigations ���'1= 1 Congress Street, Suite 100 ti'_°Ii t, Boston, MA 02114-2017 '1..0 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly 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.❑■ I am a employer with 35 4. n I am a general contractor and I employees (full and/or part-time).* have hired the sub contractors 6. [' New construction listed on the attached sheet. 7. ❑■ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub contractors have 8. n Demolition workingfor me in anycapacity. employees and have workers' 9. n Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions 3.17 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.❑ Other comp. insurance required.] *My 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. tContractors 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: Republic Franklin Insurance Co. Policy#or Self-ins. Lic. #:CPP5448253 Expiration Date:4/15/24 Job Site Address: Coolidge Apartments, 48 Round Hill Rd. 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DI or insurance coverage verification. I do hereby certify der e pains and penalties of perjury that the information provided above is true and correct. Signature: li�4roc Dat e:10/20/23 Phone#: 86 -265-3805 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: NORTSHE-01 LPICCININNI ACORO CERTIFICATE OF LIABILITY INSURANCE DATE 10/17IDD/YYYY) 0/17/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAMCONTACT Lisa Rogers E: AssuredPartners New England,Inc. PHONE FAX One Financial Plaza (A/c,No,Ext):(603)399-6408 (A/C,No):(603)399-6408 Hartford,CT 06103 E-MAULS$:Lisa.Rogers a(�AssuredPartners.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Republic Franklin Insurance Co. 12475 INSURED INSURER B:Utica Mutual Ins.Co. 25976 NorthEastern Sheet Metal Co.Inc. INSURER C:Utica National Ins.of Texas 43478 6 Niblick Rd. INSURERD: Enfield,CT 06082 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 TYPE OF INSURANCE ADDLISUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD,WYD IMMIDDIYYYYI IMM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR CPP5448253 4/15/2023 4/15/2024 DAMAGE TO RENTED 100,000 PREMISES(ga occurrence) $ 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 X JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO 5437470 4/15/2023 4/15/2024 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS VyN BODILY INJURY(Per accident) $ AUTOS ONLY AUTO ONLY (Peer aEaodent)AMAGE $ B X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE CULP 5448254 4/15/2023 4/15/2024 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 $ C WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY STATUTE OTH- ER 5438940 4/15/2023 4/15/2024 1,000,000 ANY OFFICER/MEMBOER PROPRIETEXCLUDED?ECUTIVE T N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1000,000 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) Job:Coolidge Apartments,Evidence of Insurance for Sheet Metal Permit Officer Excluded under Workers Compensation:Thomas Messenger CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityof Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. Building Department Puchalski Municipal Building 212 Main St. AUTHORIZED REPRESENTATIVE Northampton,MA 01060 . .4kts ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD MASSACHUSETTS DRIVERS L E NOT FOR FEDERAL ID 0410412018 S60331614 EXP DOB — , w,A , 0812512023 08/25/1969 1 ' DMss REST END NONE NONE I. " I MESSENGER . "'AV. THOMAS J 88 PEASE RD EAST LONGMEADOW,MA 01028.3111 ErEs BLU SEX M -HGT 5'40" (� DD 0Y0572018 Rev 02/2E2016 08/25/69 v COMMONWEALTH OF MASSACHUSETTS DIVISION OF OCCUPATIONAL LICENSURE BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE MASTER-UNRESTRICTED THOMAS J MESSENGER NIBLICK RD - ENFIELD,CT 06082-4456 �J 2223 0812812025 457181 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER v COMMONWEALTH OF MASSACHUSETTS DIVISION OF OCCUPATIONAL LICENSURE BOARD DF SHEET METAL WORKERS ISSUES THE FOLLOWING t ICENSE BUSINESS THOMAS J MESSENGER NORTHEASTERN SHEET METAL CO INC.GT DBA TJM SHEET METAL. •MA 6 NIBLICK RD ENFIELD,CT 05082 519 04.26J:i 2d 2. :64 LICENSE NUMBER E'IRATION DATE SERIAL NUMBER