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32A-140 (5) 109 MAIN ST - 2ND FLOOR SM-2017-0034 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON GIS It: 9961 " Map: 32A._ Block 140 . SHEETMETAL PERMIT Lot: OOI A A Permit SHEETMETAL Category: ISHEETMETAL Permit# SM-2017-0034 PERMISSION IS HEREBY GRANTED TO: Project ft JS-2017-001133 68 Contractor: License: Est.Cost: $37,680.00 Expires: Fee Charged:�$50.00 NORTHEASTERN SHEET METAL Sheetmetal-2223 08/28/2015 Balance Due:i$.00 Owner: NIS BUILDING LLC C/O HPMG #of Fixtures: Applicant: NORTHEASTERN SHEET METAL CO INC DigSafe# AT: 109 MAIN ST-2ND FLOOR UseGrcup ConstClass ISSUED ON: 22-Dec-2016 AMENDED ON: EXPIRES ON: TO PERFORM THE FOLLOWING WORK: ALL HVAC SHEET METAL DUCT WORK THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Sheetmetal REC-2017-002378 02-Dec-16 31665 $5000 212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:Ihasbrouck`la-,northamptonma.gov GeoTMSA 2016 Des Lauriers Municipal Solutions,Inc. File H SM-20I 7-0034 APPLICANT/CONTACT PERSON NORTHEASTERN SHEET METAL CO INC ADDRESS/PHONE 6 NIBLICK RD (860)265-3805 () PROPERTY LOCATION 109 MAIN ST-2ND FLOOR MAP 32A PARCEL 140 001 ZONE CB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT �Q Fee Paid Building Permit Filled out Fee Paid Tvpeof Construction: ALL HVAC METAL DUCT WORK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 2223 3 sets of Plans/Plot Plan THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON 1 MATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER: § Intermediate Project: Site Plan AND/OR Special Permit with Site Plan Major Project: Site Plan AND/OR Special Permit with Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee -rmit j. Street Co mission Permit DPW Storm Water Management Si Si . re o Building Officia Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact the Office of Planning&Development for more information. Commonwealth of Massachusetts City Of Northampton Date: 17- I I 1.6 Sheet Metal Permit Permit#c5i j--! 7- 3,7/ Estimated Job Cost: S 31") , 6 Bn Permit Fee: S 60 Plans Submitted: YES X NO Plans Reviewed: YES NO Business License# 519 Applicant License # 2,223 Business(IInformation: Property Owner/Job Location Infommation: Name: IsJOr E • _ . . - _ _• }qI Name: MS .By i14); t� LLC CfoHpY"3 Street: 6 f , b La, LC-o . street: JO9 " N.^ 5� �._ 1%4 R9or City/Town: jn-R e-L�y Cr City/Town: /V o r kv,nniorhamikA Telephone: g 60 - us- 3 x o f Telephone: A/ 1 A Photo I.D. required/ Copy of Photo I.D. attached: YES x NO Staff Initial 3-1 /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 X Retail _ Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft.X over 10,000 sq. ft. Number of Stories: 1 C 2.b Roo Sheet metal work to be completed: New Work: Renovation: X- ❑VAC K- Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to he done: All H'LAL S_L..e2 Metz 1--]Irl-+ work *vr - -L ID_C1 nL4 2r� `YL9r fr6iCc Per +b`c—_- __ r 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, $100.00 Commercial i INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yesl[y�/ No If you have checked Yes, indicate the type of coverage by checking the appropriate box below:et A liability insurance policy I[y Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee dnr%not h,vs the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waivosthis requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owners Agent By checking this box0,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO prngrecc Import-Bine. trite ('nmmenty pin.rl Incpertino nate Comments Type of License: By ❑Master Title ❑ Master-Restricted bleat I City own - ❑Journeyperson Signature of Licensee Permit/ --- OJourneyperson-Restricted License Number: Fee$ ❑ Check at www mach gnvldpl Inspector Signature of Permit Approval The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations E1 I Congress Street, Suite 100 \--1,17,; Boston, MA 02114-2017 ti www.inass 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 #:860265-3805 Are you an employer? Check the appropriate box: Type of project(required): I.. I am a employer with 44 4. E I am a general contractor and I —x have hired the sub-contractors h. 111 New cvnslruction employees (full and/or part-time).* 2.0 I am a sole proprietor or partner- These on the attached sheet. II Remodeling ship and have no employees These sub-contractors' have 8. Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance., required] 5. nWe are a corporation and its 10.[ Electrical repairs or additions officers have exercised their 11. repairs or additions 3.❑ I am a homeowner doing all work Plumbing P myself [No workers' comp. right of exemption per MGL myself Roof repairs insurance required.] ' c. 152. §1(4).and we have no employees. [No workers' 13.❑Other comp. insurance required.' _ An applicant hat checks box a I must also fill out the section helots showing their workers compensation policy information. t lIomonviners who submit thk aflidmit ind ling foe) arc doing all work and then hire outside contractors m usl> bmit a new affidavit indicating such. t('ontruders that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have empioyees. lithe cub-crory actors hem emplopx>they must provide their .workers"camp.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:Arbella Indemnity Policy#or Self-ins. Lie. #;422005206101 Expiration Date:041#1512017 Job Site Address: 109 Main St., 2nd Floor City/State/ZipNorthampton, MA01060 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 MOL c. 152 can lead to the imposition of criminal penalties ofa 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 t A CI insurance coverage verification- I do herd!),certify n as; fhe pains and penalties of perjury that the information provided above is true and correct. �Si mature: V�� (�� Date:12/1/16 ......... Phone#: 860-2c5-3805 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License t# 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#: -y-� NORTH23 OP ID:AO ALCORD CERTIFICATE OF LIABILITY INSURANCE DATE A 12/01/22/01/2 TI 016 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 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: Tracy fiber Bouvier Insurance PN 'FAT 29 North Main Street yn+c-tc.no.Eaq,860-232-1491 ;Lmo Not 860.232-6637 West Hartford,CT 06107 E'reAll Bouvier Insurance ADDRESS:•hiller@binsurance.com INSURER/SI AFFORDING COVERAGE NAICY INSURER A Arbella Protection Insurance _. usuRED NorthEastem Sheet Metal M'SURERB:Arbelia Indemnity Company,Inc. INSURER C. 6 Niblick Road - - - -' - Enfield,CT06082 INSURER°.. INSURERS: 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 REDUIREMENT, 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. /NSP --_ AOOLiusi - — P°LICYLFF POLICY EXP - - - - JTR TOLE OF INSURANCE INP WVo POLICY NUMBER IMMJOQ(VYYVI IMMIDUMEVYI LIMITS GENERAL LUOLrr EACH DCCILELLEUDE 5 1e000,000 A � X COMMERCIAL GENERA_Luhlm Y' 8500058666 04/15/2016 04115/2017-'6A GE o RENTER --'_ --- 25Q,000 ,_. F IDES Egp[g4^enm a _ I CLAIMS-MADE X OCCUR MED EXP(Any one person) s 10,000 PERSONAL anUV INJURY S 1.000.000 ><NERa >G<,Recv.TE s 2,000,066 GENL AGGREGATE LINT aFix icsaER raOaels.ecwo-rvnecs 2,008,006 POLICY X JPRO- LOC _ 5 AUTOMoe4e LIABILITY CARNE ROUE LIMIT 1s 1,0.00,000 A X ANY AUTO 1020019056 04/15/2016'04/15/2017 NODRY INJURY,Per person) a -FLL OWNED SCHEDULED _CODLYINJURY We:amdecll AUTOS Atir05 t HIRED AUTOS OS _:EREDCDAMAGE IDENT . 5 _ • X UMBRELLA UAB X 'OCCUR EACH OCCURRENCE 5 5,000,000 A Excess um 4600056667 04/15/2016104/1512017 AGGREGATE 5,000,000CISIMSMe _ ICED X-RETENTIONS 10,000 _ s I WORKERS COMPENSATION v ` ATU5 Orth AND EMPLOYE LIABILITY X TORY ASIS EF __.. .. B ANYROPVE i RTNER:EXECUTVE "'" 422005206101 04/15/2016104/15/2017 a L EACH ,CIDENT $ 500,000 OFFICER/MEMBER EXCLUDED, NIA (Mandatory In NR E.L.DISEASE-EA EMPLOYEE S500,000 under DESCRIPTION _ _. .. _.. I w OF OPERATIONS blow E L DISEASE POLICY LIMIT S 500,000 • DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule.II more space is required, Evidence of Insurance for sheet Metal Permit. Job: 109 Main St. , 2nd Floor Renovation 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 Aur ORIzEOREPRESENTALIVE 212 Main St. Northampton,MA 2 —l� 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD v COMMONWEALTH OF MASSACHUSETTS BOARQOF SHEET METAL WORKERS ISSUES ThE FOLLOWING LICENSE AS A. MASTER-UNRESTRICTED THOMASJ.MESSENGER z S NIBLICK RD `ad. ENFIELD CT 06082- 456 2223 0812012011 1810, �4 v COMMONWEALTH OF MASSACHUSETTS ; BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE AS A BUSINESS THOMAS.1 MESSENGER �. NORTHEASTERN SHEET METAL CO INC DBATJM SHEET METAL-MA \t I, NIBLICK RD - 4 ENFIELD,CT 06082 519 04126/2018 26469 LICENSE NUMBER ' RATION.ATE SERIAL.NUMBER -ASSACLIUSETTS pp��yy�E(� LICENSE ,Eo te NONE'°S_st1331v. 3614 NGER e 88 PEASE RD tE LONGMEADOW,MA 01028.3111 I