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23B-046 (290) SM-2024-0008 30 LOCUST ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23B-046-001 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-2024-0008 PERMISSION IS HEREBY GRANTED TO: Project# ADDITION 2023 Contractor: License: NORTHEASTERN SHEET METAL CO Est. Cost: 679800 INC Const.Class: Exp.Date: Use Group: Owner: COOLEY DICKINSON HOSPITAL INC Lot Size (sq.ft.) Zoning: M/WP Applicant: NORTHEASTERN SHEET METAL CO INC Applicant Address Phone: Insurance: 6 NIBLICK RD (860)265-3805 CPP5448253 ENFIELD, CT 06082 ISSUED ON: 01/22/2024 TO PERFORM THE FOLLOWING WORK: HVAC 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 cA 311 irS Fees Paid: $50.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner J Commonwealth of Massachusetts City Of Northampton Date: 1/12/24 Sheet Metal Permit Permit# Sm-.4 y- Estimated Job Cost: $679,800 Permit Fee: $50.00 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 1 Commercial: Office Retail Industrial Educational Institutional X Other E-Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. X Number of Stories: 1 basement X Sheet metal work to be completed: New Work: Renovation: and roof 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 ED / Endo 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, $100.00 Commercial INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes111 No El If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑■ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee r1pPQ not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waivPcthis requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this boxl],I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Progrect Increctinns Date Comments Final Increct on Date Comments Type of License: By ■❑ Master 1/1444 Title ❑ Master-Restricted Thom J. Messenger - President City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted Master-2223,Business 519 License Number: Fee$ ❑ Sheet Metal Business x �� }� Check at www macc gnv/rlpl S4T I/P" 0111 Inspector Signature of Permit Approval The Commonwealth of Massachusetts *_ Department of Industrial Accidents I_W! h 1 Office of Investigations _toali_ 1 Congress Street,Suite 100 Boston,MA 02114-2017 �''''_�•� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizationdividual): NorthEastern Sheet Metal (Business/Organization/Individual): 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): 1.0 I am a employer with 36 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ID New construction listed on the attached sheet. 7. 0 Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in anycapacity. employees and have workers' p ty 9. ❑Building addition [No workers' comp.insurance comp.insurance.: required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.111 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152,§1(4),and we have no 13.❑Other 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. ;Conductors 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: 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 again the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA r nsur ce coverage verification. I do hereby certify u r ns and penalties of perjury that the information provided above is true and correct Signature: f A!�/ iZ 1 Date:1/12/24 Phone#: 860-2 -3805 Official use only. Do not write in this area, to he 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 DATD/YYYY) 1/10/210/2024 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 uti€ACT Lisa Rogers AssuredPartners New England,Inc. PHONE FAX (A/c, o,Ext):(603)399-6408 I ow,No):(603)399-6408 One Financial Plaza Hartford,CT 06103 itlAss:Lisa.Rogers©AssuredPartners.com INSURERS)AFFORDING COVERAGE NAIC N INSURER A: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 ADDL SUBR - POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYYJ_,.(MM/DDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE L X OCCUR CPP5448253 4/15/2023 4/15/2024 DAMAGETORENTrr 100,000 _ PREMISES(Ea occurrence) $ -- — MED EXP(My 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 - BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS ONLY i_Perr axRdent)AGE g 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 ER R , ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N5438940 4/15/2023 4/15/2024 E.L.EACH ACCIDENT $ 1,000,000 OFFIC Rory In NH)EXCLUDED? Y NIA 1,000,000 E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Officer Excluded under Workers Compensation:Thomas Messenger Evidence of Insurance for Sheet Metal Permit. Job: Cooley Dickinson Hospital-ED/ENDO Renocation 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 11de✓e'aaa ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • MASSACHUSETTS DRIVER'S I N3E l•,t NOT FOR FEDERAL ID�� 5s NUMBER `! .r 0410412018 S6033161 4' ERR DOB 08/25/2023 08/25/1969 CLA REST ENO �i DMss NONE NONE l. MESSENGER THOMAS J 88 PEASE RD ' EAST LONGMEADOW,MA 01028-3111 h4'"", EYES BLU SEX M Hcr 5'-10" (�QQ ��}} ND 04105'2018 Rey0212212016 08/25/69 •- COMMONWEALTH OF MASSACHUSETTS DIVISION OF OCCUPATIONAL LICENSURE BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE MASTER-UNRESTRICTED THOMASJMESSENGER 6 NIBLICK RD ENFIELD, CT 06082-4456 \ 2223 0812812025 457181 LICENSE NUMBER EXPIFIATOON DATE SERIAL.NUMBER • COMMONWEALTH OF MASSACHUSETTS DIVISION OF OCCUPATIONAL LICENSURE BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE BUSINESS THOMASJMESSENGER NOR HEASTERN SHEET METAL CO INC -GT \k 't..! DBA TJM SHEET METAL MA 6 NIBLICK RD ENFIELD, CT 05082 l`k 5 04.25 2 s 24 21 , LICEN' ;MBER EIMPATION DATE SERIA RF r