22B-043 (5) ' r e 2 m : Remy H = a r r o w A t Phillips I n s u r a n c e Agency, Inc FaaID To Inspector to L ouis H3 rook Date: 1/21t2010 11:07 AM Page: 1 of
i
1 ACORD CERTIFICATE OF LIABILITY INSURANCE OPID RH 1 DATE {MAVDDA YY)
CROCK -1 1 01/21/10
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
PHILLIPS INSURANCE AGENCY INC HOLDER. THIS CERT1FiCATE DOES NOT AMEND, EXTEND OR
97 Cfat TF 1 , R STREET ALTER THE COVERAGE AFFORDED EY THE POLICIES BELOW.
CHICOPEE MA 01013
Phone: 413-594-5984 Fax: 413-592-8499 I INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Selective Insurance 12572
INSURER B: A. I. M. Mutual Ins. Co.
Crocker Building Co INSURER C.
186 Stafford St INSURER
Springfield MA 01104
: NSURER E:
COVERAGES
TriE POLK:IEG OF iNGURANCE LISTED BELOW HAVE EsEEri iSSi)ED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD iNDiCATED. NOTWITHSTANDING
ANY I2tUUII2*MtN1, ItL2M DR C N2LN 11LNJ 01- ANY ILNJI HACI LW. L0 Ht12 L ICIJMCNI WII11 I-'EL 1 I 0 WHICH !HIS Ct12III -WAIL MAY 1St ISSUtL1 O12
MAY PERTAIN, THE IN.SI IRAN'E AFFORDED RY TI-IF P( ICIFS r7FSf'RIRFr t HFRFIN IS SI /R. IFC.T TO AI I THE TFRMS, FXCI I ISIONS ANr7 t ONnmONS OF SI ICH
POLICIES. AGGREGATE LIMITS FikOVVN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
1 R L YULIt.Y lthtl.INE H'ULI1.Y t)CI^RtAI(JN
LT TYPE OP INSURANCE POLICY HOER LtMRS
_ DATE �MMfDplYY) DATE (MMIDDMr)
GENERAL CLAIMS AD IALHU(CCH-0tNCt $ 1000000
A ,..
X ccxvRC)AL GEN ERAL LIA BIUrr 518 8808700 04/ 0 1/09 04/01/10 PREMISES tEaoccurerlce) I $ 100000
l CLAIMS MADE +f X CCUR ! 1 M o D PKP (Any one person) I $ 5000
H tt 1 tHOUNAL sALYV iN,)t <v $ 1000000
-- I I rO!*J - Ar 1 $ 2000000
GENT. AGGREGATE LIMIT ArrLICG P ER' I 1 PIRODUCTG - COMP /OP AGO 1 $ 2000000
POLICY r i -c 1 LOC
_
AUTOMOBILE LIABILITY COWED SINGLE LIMIT , 1YoQQQo
I ANY AUTO 89092137 04/01/09 1 04/01/10 1 CE9 aeddent) — I • ALL OWNED AUTOS 1
I I BODILY INJURY $
A I I X SCHEDULED Aut05 (Per person)
A lc HIED ALTOS, I I BoDr y
A I X NON OWNED ALTOS I I (rer (LV oc ci ir- u dent ) $
�__ L.a _.. VED / PROPERTY DAMAGE
per mown)
I G RAfiE LL46LL.IfY -- AUTO ONLY - EA ACCIDENT $
An1VAIIIIt °THEPTHAN I- A AI:I: I
4_--.-------H
I 1 1 I Ir� ONLY: AGG $
1 EXCESSAPHRELLALiAINLUTY ( I EACFiOCCURRENCE I $ 5000000
i Dcc
A I I CLAIMS MADE 1 04/01/10 I E
AOG LATE I $ 5000000
r X I 5182802700
04/01/09 1 I I I$
I DEDUCTIBLE I I $
RETENTION $ I 1— 1 $
INGRKERS cCIM PENS,ATION AND I I _ TmaIMITS I X 1
EMPLOYERS' LIABILITY
8 T4t4Z9005450012009 I 04/01/09 I 04/01/10 E.L.EAcHAccit,Erar I $ 500000
ANY PROPRIETDR)PARTNERJEXECUTIVE
OFFIC I E.L. DISEASE - EA EMPLOYEE' $ 500000
If yes. describe under
SPECIAL PROVISIONS [Mow I c . DI3CA3C - POLICY LIMIT I $ 500000
OTHER
A Rented /Leased 1 3188808700 I 04/01/09 04/01/10 Equipment $200,000
Equipment 1 i Pecl $500
• DESCRIPTION OF OPERATIONS/ LOCATIONS 1 VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Interior Build Out
CERTIFICATE IiOOLDI:R CANCEC A11Ofi -- - -
CITYOE SHOULD OULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE MIDI-MHO INLRIRER WILL ENDEAVOR TO MAL 20 DAYB WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO DO SO SHALL
City of Northampton IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Inspector Louis Hasbraok
128 Locust St.cleet REPRESENTATIVES. Northampton MA 01060 AUTH REPRES ATIVE s
ACORD 25 42001108) I � T• � j @ A 1988
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tin* Authority (circle one): .
ard od4eldth 2. Buildl I)
spartsaeat 3, Cityfrawst Clerk 4. Ilia tr I e 4 L I "Inspector 5. Plambing /asp actor
Bard
tiler . - . -
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Phone 41: . .
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The Commonwealth of Massachusetts
Department of Industrial Accidents
( ~ Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information / / i:e' Please Print Legibly
A4, Z 4' 6 ' 4'L
Name ( Business /Organization/Individual):
oxed
Address: 2 �� '>/vR4 /I-
-
City /State /Zip:
G/�''/w'''`t /`L/'1 Phone #: S ��'"`
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 5- 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction
listed on the attached sheet. 7. Remodeling
2. [1] I am a sole proprietor or partner-
ship and have no employees These sub - contractors have g. ❑ 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. Ei 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. ❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
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. , A► .. '
Insurance Company Name: re / /� `` " /474-6-./7/
7
Policy # or Self -ins. Lic. #: 9 /1 3 / `� 7 Expiration Date: 77d /s'
Job Site Address: ` �w�7 t /� 3 City /State /Zip: 1 ,
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 verification.
I do hereby cer unde he pains and enalties o perjury that the information provided above is true and correct.
Signature: I( Date: / ( '//.."
Phone #: y� JO J - G
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 #:
•
•
Version1.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No
SECTION 11 - OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, as Owner of the subject property
hereby authorize
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
, 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 pains and ,enalties of_perjury
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: . 13 t RA 4h. - ...,,.. CS' t- .....
License Number
iota Sx C..c.I
Addr ss Expiration Date
1 j' - «' w •3 3 0�
Signature Telephone
SECTION 13 = WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
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 0 No 0
Version1.7 Commercial Building Permit May 15, 20010
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
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 Number
Signature Telephone - Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Telephone Expiration `" ........ _
Signature Tel ..,...,� .. _ _.._
p Date
9.3 General Contractor
?/Lc a _..... (Lc lyk, _ .. 4 . ._,.._ _.. .,_ Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
,;()10 /f
S ds
Signature Telephone
' t
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW (3 YES 0
IF YES: enter Book Page and /or Document #!
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained to Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location: '.
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 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 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
i. r
Version1.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other 0
Brief Description Enter a brief description here. /N.c. f / A s 7,,,,4 y'A -/ 7/r0
Of Proposed Work:
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑
A -4 ❑ A -5 ❑ 1 B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B - I ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 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 BUILDING UNDERGOING RENOVATIONS ADDITIONS AND /OR CHANGE IN USE
Existing Use Group:
Existing Hazard Index 780 CMR 34): . _...,.. ..,..,,,„..._.w Proposed Hazard Index 780 CMR 34): ._,
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
1st 1 s �. .„ �, a.., m.
2" d
2 nd
3
3 ro
`d
4
4
u,
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:
PubliciZ1 Private ❑ Zone ,,,, Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Versionl.7 Commercial Building Permit May 15, 2000
Department use ol�ly
City of Northampton Stat s Uf Permit
Building Department Curl CutlDnveway Perrtt N
212 Main Street SewerlSepticAtrallabttity
Room 100 WateriWell i4vailability
Northampton, MA 01060 Two Sets ofSti
phone 413- 587 -1240 Fax 4- 13-58.7 -i 2-- „ - r "' o srt fans
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR O Y DWELLING
JAN
SECTION 1 - SITE INFORMATION
1.1 Property Address:
„this section to be completed by office
2- Y A ii /iie* f Map Lot Unit
f r 11.4v -a, 1114 Zone Overlay District
�.. , Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) i Y1 d Current Mailing Address:
L _,J/7 7 { _ l
Signature Telephone
2.2 Authorized Agen
�... __ . � r. , �o_ a.m
Name (Print) liYi„�i� dZ G' � #.dh' Cu
Trent Mailing Address:
Si -117 Telephone S /or n ~^^
n ; L
1
SECTION 3 ESTIMATED ONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ova lip (a) Building Permit Fee
�
2. Electrical l µ � _ (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) _... .__._._ _ ._..
5. Fire Protection '
6. Total = (1 + 2 + 3 + 4 + 5) // 2 47 Check Number lf,
1 1,7: 27 —
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0676
APPLICANT /CONTACT PERSON CROCKER BUILDING CO INC
ADDRESS /PHONE 186 STAFFORD ST SPRINGFIELD (413) 737 -7803
PROPERTY LOCATION 296 NONOTUCK ST
MAP 22B PARCEL 043 001 ZONE GI(100) / /WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid p ��/
Typeof Construction:_CONSTRUCT INTERIOR 1 HR SHEETROCK PARTITIONS FOR STORAGE ROOMS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 067805
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORIVIATION 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
Permit from Elm Street Commission - Permit DPW Storm Water Management
Demolition Delay
c
f/2-0/ /0
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.
296 NONOTUCK ST BP- 2010 -0676
GIS #: COMMONWEALTH OF MASSACHUSETTS
:F l CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2010 -0676
Project # JS- 2010- 000989
Est. Cost: $12000.00
Fee: $72.00 PERMISSION IS HEREBY GRANTED TO:
Coast. Class: Contractor: License:
Use Group: CROCKER BUILDING CO INC 067805
Lot Size(sq. ft.): 130680.00 Owner: NONOTUCK MILLS LLC
Zoning: GI(100) / /WP Applicant: CROCKER BUILDING CO INC
AT: 296 NONOTUCK ST
Applicant Address: Phone: Insurance:
186 STAFFORD ST (413) 737 -7803 Workers
Compensation
SPRINGFIELDMA01104 ISSUED ON:1/20/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT INTERIOR 1 HR SHEETROCK
PARTITIONS FOR STORAGE ROOMS
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 1/20/2010 0:00:00 $72.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo