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22B-111 Aon Risk Services CERTIFICATE OF INSURANCE ISSUE DATE: 2/19/09 PRODUCER Aon Risk Services, Inc. of Illinois THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO The Elks Insurance Program RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND 300 South Wacker Drive, Suite 700 OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Chicago, IL 60606 -6670 COMPANIES AFFORDING COVERAGE INSURED Benevolent and Protective Order of Elks of U.S.A Grand Lodge — Local Lodges of the Order COMPANY LETTER A Old Republic Insurance Company 2750 N. Lakeview Avenue COMPANY LETTER B Westchester Fire Insurance Company Chicago, IL 60614 -1889 COVERAGES 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. CO TYPE OF INSURANCE POLICY NUMBER POLICY POLICY LIMITS LTR EFFECTIVE DATE EXPIRATION DATE GENERAL AGGREGATE $1,000,000 PER OCCURRENCE $1,000,000 GENERAL LIABILITY PRODUCTS - COMP /OP AGG $1,000,000 IS COMMERCIAL GENERAL LIABILITY 0 3/31/09 03/31/10 PERSONAL & ADV INJURY $1,000,000 MWZY 58112 FIRE DAMAGE (ANY ONE FIRE) $1,000,000 A ❑ CLAIMS MADE (EI OCCUR LIQUOR LIABILITY - EACH $1,000,000 O LIQUOR LIABILITY COMMON CAUSE LIQUOR LIABILITY $1,000,000 AGGREGATE AUTOMOBILE LIABILITY MWZY 58112 03/31/09 03/31/10 EACH ACCIDENT $1,000,000 A 0 HIRED AUTOS EACH ACCIDENT $1,000,000 O NON - OWNED AUTOS EXCESS LIABILITY G22012526004 EACH OCCURRENCE $9,000,000 ❑ UMBRELLA FORM 03/31/09 03/31/10 GENERAL AGGREGATE PER $9.000,000 B 0 OTHER THAN UMBRELLA FORM ++ LOCATION _ I DESCRIPTION OF OPERATIONS/LOCATIONS/VECHICLES /SPECIAL ITEMS Insured Lodge: Benevolent and Protective Order of Elks, its Subordinate Lodges and State Associations Event: Benevolent and Protective Order of Elks "Hoop Shoot" Free Throw Program Date: 03/31/09 through 03/31/10 THE CERTIFICATE IS PROVIDED AS EVIDENCE OF GENERAL LIABILITY INSURANCE COVERAGE TO SCHOOL BOARDS, DISTRICTS, MUNICIPALITIES OR OTHER LANDLORDS AND PROPERTY OWNERS OF FACILITIES USED BY THE ELKS FOR THE "HOOP SHOOT" FREE THROW PROGRAM Certificate Holder is named as Additional Insured CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 3 ) DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AON RISK SERVICES, INC. OF IL - PraurAD • WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company Burlington, Massachusetts NCCI NO 26158 (800) 876 -2765 POLICY NO. 1 VWC 6009899012010 PRIOR NO. ) VWC 6009899012009 ITEM 1. The Insured Northampton Lodge 997 Mailing Address: c/o Treasurer Florence MA 01062 17 Spring Street (No. Street Town or City County State Zip Code ❑ Individual ❑ Partnership ❑ Corporation ® Other Non - Profit Corp. FEIN 04- 1079695 Other workplaces not shown above: 2. The policy period is f /02/2010 to 10/02/2011 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 our liability under Part Two are: Bodily Injury by Accident $ 10 0 , 0 0 0 each accident Bodily Injury by Disease $ 5 0 0 , 0 0 0 policy limit Bodily Injury by Disease $ 100 , 0 00 each employee • C. Other States Insurance: Coverage Replaced By Endorsement WC 20 03 06A 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 Estimated Per $100 Estimated Code Total Annual of Annual No. Remuneration Remuneration Premium INTRA 156197 SEE EXTENSION OF INFORMATION PAGE Minimum premium $ 213.00 Total Estimated Annual Premium $ 915.00 As indicated, interim adjustments of premium shall be made: Deposit Premium $ 959.00 ® Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly MA Assessment Chg. $644. x 6.8000% $44.00 This policy, including all endorsements, is hereby countersigned by G,reeda �/ 08/05/2010 Authorized Signature Date GOV GOV KIND PLACING CLAIM NAME SAFETY STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP King & Cushman Inc MA 9061 2 602 P O Box 447 WC 00 00 01 A (11-88) Northampton, MA 01061 Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 6 =� = 600 Washington Street '' Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name (Business /Organization /Individual): It)OI 4t �v1 •yJb) j P6 Address: / 7 5P �( `f T City /State /Zip: F EA C " 0 1 0 0-Phone #: 1 4) 3 L -0 cm 7 Are you an employer? Check the appfopriate box: Type of project (required): 2 1. ❑ I am a employer with 4. ❑ 1 am a general contractor and 1 ❑ have hired the sub - contractors employees (full and/or part- time). * 6. 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 employees and have workers" g for me in any capacity. P it Y 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ 1 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.] '' c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box # I must also till 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: /144'1'7 t6LtkCit l t` • CO r Policy # or Self -ins. Lic. #: kiwG (oOO Q `r CZL.)l 0 Expiration Date: /% +/' t'1 Job Site Address: / 7 11 9 ` Ftx'` 6 'N' 7 l t O kity /State /Zip: t'0''1 T 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: 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 #: Version 1.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes ® No 1g SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT , as Owner of the subject property hereby authorize to 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 penalties of perjury. Print Name Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : GJ ' 1 � „of ' 5r, • License Number 1 445 C-icuxe c•- !al - OWE) 7 3 7 Address , / / fin Expiration Date 6/3 /94- 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 r6 No A t e 0) 5 �L Version1.7 Commercial Building Permit May 15, 2000 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 Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature Telephone Version 1.7 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 L: R: L: R: 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 DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW o YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Q , 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 ® 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 o NO YES, then a Northampton Storm Water Management Permit from the DPW is required. r Version 1.7 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 >t Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description Enter a brief description here. Of Proposed Work: e j"�1.1 r d > j t - r -I NG t NJ 5 'e.9 SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ A -4 ❑ A -5 ❑ 1B ❑ • B Business ❑ 2A ❑ E Educational ❑ 2B 1 ❑ 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: Proposed Use Group: Existing Hazard Index 780 CMR 34): 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) 0 e r4) y 4 r-1) 1 st 1st /X i 1 2nd 2 nd 3rd 3 rd 4 th 4 th Total Area (sf) Total Proposed New Construction (sf) Total Height (ft) /0 1 Total Height ft 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone Municipal ❑ On site disposal system w Version 1.7 Commercial Building Permit May 15, 2000 Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit - �,CQ, 212 Main Street Sewer /Septic Availability 2 - loom 100 WaterNVell Availability GC-: Nol MA 01060 Two Sets of Structural Plans phone 413 -587 -1240 Fax 413- 587 -1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, O(DEMOLISHINY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING '' SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office 17 51)P t 57; Map Lot Unit Zone Overlay District f LoL erv� J i 44 - 611102 y Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: i1/4101410 El-i 1-01)6 e 17 5P 5T Name (Print) Current Mailing Address: F (At clice Ml- Cu)!&2 Signature Telephone '-11 3 - 53 - 0 ' l ` 7 2.2 Authorized Agent: ,.(_:/.)' ' ii..1i9 0 0.00 C.I . ,..T 0- ©A €iCe -i'i cr" •E z. Name (Print) Current Mailing Address: ■ -- 41 . 'f27 -0711 Signature ( ` ' a. Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (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) Check Number / � 0e- t — This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP -2011 -0398 APPLICANT /CONTACT PERSON NORTHAMPTON ELKS LODGE #997 ADDRESS/PHONE 17 SPRING ST FLORENCE (413) 584 -0997 0 PROPERTY LOCATION 17 SPRING ST MAP 22B PARCEL 111 001 ZONE SI(98)/URA(2) //WP/WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: DEMO 12 X 12 SHED New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 54749 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN FQJtMATION 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 / 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. ter; _ • BP- 2011 -0398 GIS #: COMMONWEALTH OF MASSACHUSETTS t t 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: BUILDING PERMIT Permit# BP- 2011 -0398 Project # JS- 2011- 000661 Est. Cost: $0.00 Fee: $20.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: GREGORY J ZAKRZEWSKI 54749 Lot Size(sq. ft.): 134295.48 Owner: NORTHAMPTON ELKS LODGE #997 Zoning: SI(98)/URA(2) / /WP/WSP Applicant: NORTHAMPTON ELKS LODGE #997 AT: 17 SPRING ST Applicant Address: Phone: Insurance: 17 SPRING ST (413) 584 -0997 0 FLORENCEMA01062 ISSUED ON:11/8/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: DEMO 12 X 12 SHED 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 11/8/2010 0:00:00 $20.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner