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32A-155 q,g BP- 2010 -0720 GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate WATER DAMAGE BUILDING PERMIT Permit # BP- 2010 -0720 Project # JS- 2010 - 001069 Est. Cost: $9000.00 Fee: PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PROSPECT BUILDERS INC 76106 Lot Size(sq. ft.): 914.76 Owner: MASTERS TOM & CHARONNE zoning: CB(100) / Applicant: PROSPECT BUILDERS INC AT. 4 MAIN ST Applicant Address: Phone: Insurance: P O BOX 302 (800)486 -4976 Workers Compensation EAST LONGMEADOWMA01028 ISSUED ON :211112010 0:00:00 TO PERFORM THE FOLLOWING WORK.- REPAIR WATER DAMAGE, REPLACE CEILING TILES 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: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 2/11/2010 0:00:00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo File # BP- 2010 -0720 APPLICANT /CONTACT PERSON PROSPECT BUILDERS INC ADDRESS /PHONE P O BOX 302 EAST LONGMEADOW (800) 486 -4976 PROPERTY LOCATION 4 MAIN ST MAP 32A PARCEL 155 001 ZONE CB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid 19 'Am Typeof Construction: REPAIR WATER DAMAGE, REPLACE CEILING TILES New Construction Non Structural interior renovations Addition to Existing Accesses Structure Building Plans Included: Owner/ Statement or License 76106 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I FO TION PRESENTED: pproved 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 Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay 6�4= �4 — Signature of Building Official 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 Office of Planning & Development for more information. Version 1.7 Commercial Building Permit Ma 15, 2000 City of Northampton Building Department 212 Main Street 4 G 20 10 Room 100 Northampton, MA 01060 phone 413 - 587 -1240 Fax 413 - 587 -1272 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address SECTION 2 -PROPERTY OWNERSHOJAUTHOM&O 2.1 Owner of Record �. Name (Print) Current Mailing Address: Signature Telephone 2.2 Authorized Anent: A!��T 36 mow 6 Name (Print) Current Mailing Address: y�3 e- 2 Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be : C�fflal lJse Only completed b e rmit a2plicant 1. Building 17 7 7, 2. Electrical �} 3. Plumbing 4. Mechanical (HVAC)� 5. Fire Protection — � 6. Total =0 +2 +3 +4 ±5) 7hta Section For.` i 6 Building Permit Number fate. r. <. gzu ...; Issued n. w. -v Signature: Building ommissioner /Ins ectorofBuildin s ` 9 P 9 Versionl .7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR "PROJECTS L S � HAIti b CUBIC FEET OF ENCLOSED' a, Interior Alterations xisting Wall Signs ❑ Demolition ❑ Repairs Icd' Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing[:] Change of Use ❑ Other ❑ Brief Description Enter a brief description here. iZ �"� %�� /z '�-' �" »` •�t%�� /�•y /'� r'J �' Of Proposed Work: �L`Lj,t r/L S C v�T,Qi L SECTION 5 - USE GROUP AND CONSTRUCTION TYPE ' T USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business ® 2A ❑ E Educational ❑ 213 I ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING UUILDING ):t1���1(t3lrCt->i+j�IN USE ;., . . Existing Use Group: Proposed Use Group: f Existing Hazard Index 780 CMR 34): —� Proposed Hazard Index 780 CMR 34): I ^� SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Floor Area per Floor (sf) 1 St ... .._......___ —_._ 1 St 2nd _-- ._ 2 nd 3rd — —� 3 rd 4th 4 th Total Area (sf)� — � Total Proposed New Construction sf Total Height (ft) Total Height ft 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public E] Private 0 Zone � Outside Flood Zone❑ Municipal ❑ On site disposal system[] Versionl .7 Commercial Building Permit May 15, 2000 8 i �i1I Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size �— Frontage Setbacks Front Side L: R: L: R: 0 Rear I 0 Building Height Bldg. Square Footage Open Space Footage % �] (Lot area minus bldg &paved p arkin g) # of Parking Spaces 0 Fill: I F volume &Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO ® DON'T KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW ® YES O IF YES: enter Book I Pag and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW O YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Versionl .7 Commercial Building Permit May 15, 2000 SECTION 9. PROFESSIONAL DESIGN ,AND OONS TION "'S�R1�l�$ w � P � � �� CONSTRUCTION CONTROL PURSUANT Tn' O' (INwt'11`646OJU'�'Al i . 9.1 Registered Architect: Not Applicable ❑ Name (Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration N umber Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name: Responsible In Charge o Construction Address Sign ur Telephone Versionl.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (7$0 CMWAJ0A1) Independent Structural Engineering Structural Peer Review Required Yes 0 No 0 SECTION 11 - OWNER AUTHORIZATION 0131!�G OWNERS AGENT OR CONTRACTOk2 APPLIES FOR liUILL ENO' as Owner of the subject property hereby authorize IL X7 J 1 ��� L /J �% T = to .-. act on my b twIf, in all mattem relative twwork authoffzed by this building permit application. F Signatvie of NAer Date 1Z j 1 I, - -— �l�l�� as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under ,the _ ins o perjury Print Name Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder �ZG' r l= /1 c: �% ; /b Gj License Number i"v i3� t 3 v Z c yr li,.�t �� v cr ; .t-L9 Address Expiration Date Signs a Telephone SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVlf ,Lr152s6j),,x, =. Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes � No 0 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I, 600 Washington Street Boston, MA 02111 www massgov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Leg Name ( Business /Organization/Individual): Address: Pe /.3 c? X 3 c Z City /State /Zip: L Phone #: 15.;?- S - 32-74- Are you an employer? Check the appropriate box: Type of project (required): 1. [9I am a with employer 4. E] I am a general contractor and I �— * have hired the sub - contractors 6• ❑New construction employees (full and/or part- time). 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have g. E] 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.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their I L ❑ 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 employees. [No workers' 13. El 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: i(/�q- TiG.y�� u,r�� v ✓ %iilw� Policy # or Self -ins. Lic. #: { vC e7-,,;'& Expiration Date: / Tom/1 ,> Job Site Address: _�r ly"ezz, -I; r K i Agnd Y City/State /Zip: %tI//,t- 0 1 1 60 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 DIA for insurance coverage veri I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct SiQna_ tur� t Date: /0/ U Phone #• .3z . O Z & 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 #: f 12/2/2009 %4:35 ICNE Group Marie Proulx-->DENISE 2/3 A CORD TM CERTIFICATE OF LIABILITY INSURANCE DAT (MMIDD0 PPODUCER Phone (413) 781 -2410 Fax 413 -731 -9539 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INSURANCE CENTER OF NEW ENGLAND ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P O BOX 1175 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR WEST SPRINGFIELD MA 01090 -1175 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Peerless Insurance Company 24198 PROSPECT BUILDERS INC INSURER e: National Union Fire Ins (PMC) 660 PROSPECT ST INSURER C: EAST LONGMEADOW MA 01028 -- INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICYPERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MA'f PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS Lie INSRD DATE MM /DDIYY DATE MMlDD /YY GENERAL LIABILITY CBP8532362 10/31109 10/31/10 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 PREMISES (Ea occurence) CLAIMS MADE X OCCUR MED EXP (Any one person) $ 10,000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 ,Er I'L AGGREGATE LIMIT APPLIES PER PRODUCTS- COMPIOP AGO. $ 2,000,000 -- - POLICY J PRO ECT LOC AUTOMOBILE LIABILITY BA8535262 10/31109 10/31/10 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ A X HIRED AUTOS BODILY INJURY $ X NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY- EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY AGG $ EXCESS I UMBRELLA LIABILITY CU8537064 10/31109 10/31/10 EACH OCCURRENCE $ 1,000,000 X OCCUR CLAIMS MADE AGGREGATE $ 1,000 A $ DEDUCTIBLE $ RETENTION $ Q WORKERS COMPENSATION AND WC009755950 10/31109 10/31110 roRYTLIMITS OTHER EMPLOYERS' LIABILITY E . EACH ACCIDENT $ 500, B ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E . DISEASE -EA EMPLOYEE $ 500,000 If yes, describe under SPECIAL PROVISIONS below EL. DISEASE - POLICY LIMIT $ 500,000 OTHER: DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO FOR VERIFICATION OF INSURANCE PURPOSES ONLY OBLIGATION OR LABILITY OF ANY KIND UPON THE INSURER. IT'S AGENTS OR REPRESENTATIVES AUTHORIZED REPRESENTATIVE Attention: II am 0. T ruQ , ACORD 25 (2001108) Certificate # 45711 © ACORD CORPORATION 1988