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32A-162 33 HAWLEY ST SM-2021-0047 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON GIS#: 10004 boat MnMnrory L7. Map: 32A �` .,'4 i,i�� Block: 162 � ' � � �_ SHEETMETAL PERMIT SHEETMETAL rf E'fo/ Lot: 001 e" Permit 0 Category: 'SHEETMETAL Permit# sM 2021 0047 PERMISSION IS HEREBY GRANTED TO: Project# JS-2021-002203 Est.Cost: i,$101,600.00 Contractor: License: Expires: Fee Charged:$50.00 NORTHEASTERN SHEET METAL Sheetmetal-2223 08/28/2021 Balance Due:$.00 Owner: Northampton Community Arts Trust #of Fixtures: Applicant: NORTHEASTERN SHEET METAL CO INC DigSafe# AT: 33 HAWLEY ST UseGroup ConstC lass ISSUED ON: 08-Jun-2021 AMENDED ON: EXPIRES ON: TO PERFORM THE FOLLOWING WORK: HVAC BLACK BOX THEATER THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature 'f 6 ,2 _ t Yv Fee Type: Receipt No: Date Paid: • Check No: Amount: Sheetmetal REC-2021-003839 07-Jun-21 36291 $50.00 212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:Ihasbrouck@northamptonma.gov Geo I'MS®2021 Des Lauriers Municipal Solutions,Inc. - Commonwealth of Massachusetts City Of Northampton Date: 6/3/21 Sheet Metal Permit Permit# S") J - y 7 Estimated Job Cost: $ 101 ,600 ���' - Permit Fee: $50.00 JUN Plans Submitted: YES X NO, ' 2 �O2 Plan Reviewed: YES NO 7 Business License# 519 2223 No �„ Applican License # Business Information: -E Owner/Job Location Information: Name: NorthEastern Sheet Metal Name: Northampton Community Arts Trust Street: 6 Niblick Rd. Street: 33 Hawley St. City/Town: Enfield, CT 06082 city/Town: Northampton, MA Telephone: 860-265-3805 Telephone: 413-559-9155 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 2 Commercial: Office Retail Industrial Educational Institutional Other X Basement& Square Footage: under 10,000 sq. ft. X over 10,000 sq. ft. Number of Stories: 2 1st floor 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 Northampton Community Arts Trust - Black Box Theater 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, $100.00 Commercial 4 INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yeses No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑■ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee dnac not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waivesthis requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box.,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Progress Increetinns Date Comments Final Increctinn Date Commnnt s Type of License: By ❑■ Master / AZ46 Title ❑ Master-Restricted Thomas J. Messenger - President City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted Master-2223,Business 519 License Number: Fee$ 1-1 Sheet Metal Business x Check at www mass gnv/rfpl rOCAtik., •C T11/406 6/8/a4) Inspector Signature of Permit Approval The Commonwealth of Massachusetts Department of Industrial Accidents L Office of Investigations sMr 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/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): 1.111 I am a employer with 40 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑■ 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. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 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' 13.0 Other 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. 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:Republic-Franklin Insurance Company Policy#or Self-ins. Lic. #:5438940 Expiration Date:4/15/2022 Job Site Address: Northampton Community Arts Trust, 33 Hawley 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 against a violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA f insurance coverage verification. I do hereby certify un er t ins and penalties of perjury that the information provided above is true and correct Si ature: 444 Date: 6/3/2021 Phone#: 860-26 -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#: 1 AC D® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 5/13/2021 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: John M. Glover Agency PHONE Yesenia Maggio FAX P.O. Box 700 lac.No.Ext):203-702-7924 (AIc.No):203-672-4968 Norwalk CT 06852 ADDRESS: ymaggio©johnmglover.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Republic-Franklin Insurance Company 12475 INSURED NORTSHE-02 INSURER B:Utica Mutual Insurance Company 25976 Northeastern Sheet Metal Co., Inc. 6 Niblick Road INSURERC: Enfield CT 06082 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1535240131 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. I EXP NSR ADDLTYPE OF INSURANCE INSD WVDSUBR POLICY NUMBER (MMIDD//YYYY) (MMIDDPOLICY EFF YIYYYY) LIMITS LTR INSD WVD A X COMMERCIAL GENERAL LIABILITY 5448253 4/15/2021 4/15/2022 EACH OCCURRENCE $1,000,000 DAMAGE TO CLAIMS-MADE X OCCUR PREMISES(EaENTED occurrence) $300,000 MED EXP(Any one person) $10,000 PERSONAL 8 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY JEa LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY 5437470 4/15/2021 4/15/2022 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) B X UMBRELLA LIAB _ OCCUR 5448254 4/15/2021 4/15/2022 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED RETENTION$ OT $ A WORKERS COMPENSATION N 5438940 4/15/2021 4/15/2022 X AND EMPLOYERS'LIABILITY STATUTE ERA Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A Equipment N N 5448253 4/15/2021 4/15/2022 Leased/Rented 200,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The certificate holder is an additional insured under the general liability assumed under written contract with the insured executed prior to a loss. Evidence of Insurance for Sheet Metal Permit. Job:Northampton Community Arts Trust—Black Box Theater 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 AUTHORIZED REPRESENTATIVE 212 Main Street Northampton, MA 01060 e ,4CG1.c�� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD MASSACHUSETTS DRIVERS LICENSE 4R NOT FOR FEDERAL ID ASS RUMBER `" 0410412018 S60331614 0812512023 08/25/1969 CLADM REST ENV NONENONE NONE MESSENGER iiiiiiii THOMASJ 88 PEASE RD EAST LONGMEADOW,MA 01028-3111 +:,EYES BLU IS SEX M HG//1 SODEY05'2QlERevO�1018 08/25/69 COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE ¢I -II SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE MASTER-UNRESTRICTED THOMAS J MESSENGER 6 NIBLICK RD ENFIELD,CT 06082-4456 N 2223 08/28/2021 707975 COMMONWEALTH OF M SACHUSETTS DIVISION OF PROFESSIONAL LICENSURE 30ARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE BUSINESS cc THOMAS J MESSENGER NORTHEASTERN SHEET METAL CO IN CT DBA TJM SHEET METAL-MA 6 NIBLICK RD t' ENFIELD,CT 06082 519 04/26/2022 883030 LICENSE NUMBER EX (RATION DATE SEPIA NUMBER