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23B-014 SM-2023-0003 125 LOCUST ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23B-014-001 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-2023-0003 PERMISSION IS HEREBY GRANTED TO: Project# ERV 2023 Contractor: License: ADAMS PLUMBING &HEATING Est. Cost: 37800 INC Const.Class: Exp.Date: NORTHAMPTON CITY OF BOARD OF PUBLIC Use Group: Owner: WORKS Lot Size (sq.ft.) Zoning: OI Applicant: ADAMS PLUMBING &HEATING INC Applicant Address Phone: Insurance: PO BOX 126 (413)743-2308 MCC-200-2000025-2021A ADAMS, MA 01220 ISSUED ON: 01/30/2023 TO PERFORM THE FOLLOWING WORK: INSTALL DUCT FOR ERV 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: 0\141i\JL. ICJ 7 Fees Paid: $ 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner Commonwealth of Massachusetts Sheet Metal Permit Date: I/25)93 f-- Permit# c)" 3 3 Estimated Job Cost: $ , j� Z JAN 2 7 7023 Permit Fee: $ /W / 1_ 4' Plans Submitted: YES NO L ..Plans Reviewed: YES NO - T.OF 3UiLDINc INSPECTIO07is N?RTHAMPTON,MA 01060 Business License# 128 - Applicant License# 3810 Business Information: Property Owner/Job Location Information: Name: Adams Plumbing & Heating, Inc. Name: O4)^ t�"►t,Vul ©PIA) Hein Street: 43 Printworks Dr. (P.O. Box 126) Street: 1 a S l GCv; S- City/Town: Adams City/Town: ► "Ilak�,p4e--, ,A'?4 Telephone: 413-743-2308 Telephone: 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 X Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. }( over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing )( Temp Heating/Cooling Louvers: Grease Ducts: FD&FSD: Provide detailed description of work to be done: 1 ���a� >i d✓C7 ?�^ ✓4W ei�7�ri.dr, fey j ✓114014J CoJ`( 1/QV\nerjo.r-- 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 ❑X Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this boxN,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 Inspections Date Comments Final Inspection Date Comments Type of License: By IN Master Title ❑ Master-Restricted V E City/Town Jeffre/iDaignault ❑Journeyperson ✓ Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: 3810 Fee$ ❑ Check at www.mass.gov/dpl Ojtok , , /2°43 Inspector Signature of Permit Approval ,/ '',- The Commonwealth of Massachusetts ji Department of Industrial Accidents _gin_ i= = 1 Congress Street, Suite 100 , #�c w Boston,MA 02114-2017 —N.4 ww mass.gov/dia +Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):Adams Plumbing &Heating, Inc. Address: PO Box 126, 43 Printworks Drive City/State/Zip:Adams, MA 01220 Phone #:413-743-2308 Are you an employer?Check the appropriate box: Type of project(required): I Q✓ I am a employer with 80 employees(full and/or part-time).* 7. 11 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required]t 10 ❑ Building addition -i❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑✓ Other HVAC 152,§1(4),and we have no 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. :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:Massachusetts Employers Insurance Co., Inc. Policy#or Self-ins.Lic.#:MCC-200-2000025-2023A Expiration Date:1/1/2024 Job Site Address:125 Locust Street City/State/Zip:Northampton 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 MGL c. 152, §25A is a criminal violation punishable by 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 :o$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: i�_ii/A.4I Date: //j7/y3 Phone#:413-743-2�8 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Massachusetts Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 58713 POLICY NO. MCC-200-2000025-2023A PRIOR NO. MCC-200-2000025-2022A ITEM 1. The Insured: Adams Plumbing &Heating Inc. DBA: Mailing address: P O Box 126 FEIN:**-***2575 Adams, MA 01220-0000 Legal Entity Type: Corporation Other workplaces not shown above: See Location 2. The policy period is from 01/01/2023 to 01/01/2024 12:01 a.m. standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 000124512 INTER 911837307 SEE CLASS CODE SCHEDU_E -- i Minimum Premium $416 Total Estimated Annual Premium $126,667 GOV GOV Deposit Premium $13,347 STATE CLASS MA 5183 State Assessments/Surcharges $162,739.00 x 4.1800% $6,802 This policy, including all endorsements, is hereby countersigned by / % 12/07/2022 Authorized4.ignature Date Service Office: MountainOne Insurance Agency Inc 330 Whitney Avenue 85 Main Street, Suite 100 Holyoke MA 01040 2789 North Adams, MA 01247 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. Adams Plumbing&Heating,Inc. ' ► 43 Printworks Drive,P.O.Box 126 Transmittal Cover Sheet Adams, MA 01220 Detailed, Grouped by Each Transmittal Number Lk.#9052 Northampton DPW Admin Bldg ERV System Project# 2022-40 125 Locust Street Tel: Fax: Northampton, MA 01060 Date: 1/27/2023 Reference Number: 0002 Transmitted To Transmitted By Jonathan Flagg Amy Moresi City Of Northampton Adams Plumbing& Heating, Inc. 212 Main Street PO Box 126 Room 100 Adams, MA 01220 Northampton, MA 01060 Tel:413-743-2308 Tel: 587-1338 Fax:413-743-7350 Fax: Acknowledgement Required Package Transmitted For Delivered Via Tracking Number Approval Hand Qty eke r �., Item# Item, � '� �� � '� � 0001 1.00 Sheet Metal Permit Fee 0002 1.00 WC Affidavit 0003 1.00 Plan Cc: Company Name ....., y... ; . c �i ,�_. a Remarks itg 747\4AA 7A/64i7J4) //17/1.'3 Signature Signed Date Prolog ManagerPrinted on: 1/27/2023 AdamsPlumbing Page 1