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24C-013 ^ Louis Hasbrouck From: Fire Prevention Sent: Fridoy, November 19, 2010 2:52 PM To: Louis Hasbrouck Subject: Survival Center I talked with Duane and the plans you sent regarding the Survival Center looks good from our end. Larry T, atinvOvisfyilleitla HAs4 D iefri 4 044 4 di Na ze s 4agt w I � F/ I f 044 A4/+ !a, Riggs. 1301 $agest%, M 02109-161g Nose K17)727-3200 727 -3200 fMe K17)77?-032 32 SECONDARY CONSTRUCTION CONTROL DOCUMENT (for Professional Engineers /Architects responsible for only a portion of a controlled project) Project Title: Northampton Survival Center Date: 09/01/2010 Project Location: 265 Prospect Street, Northampton, Massachusetts Scope of Project: Alterations and Renovations to the Northampton Survival Center In accordance with the 7th edition Massachusetts State Building Code,780 CMR SECTION 116.0: I, Mark W. Felgate Mass. Registration Number 47531 being a registered professional Engineer /Architect hereby CERTIFY that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: [ ] Entire Project [ ] Architectural [ ] Structural [ ] Mechanical [ ] Fire Protection [ X ] Electrical [ ] Other (specify) for the above named project and that to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all applicable laws for the proposed project. Furthermore, I understand and AGREE that I shall perform the necessary professional services to determine that the above mentioned portions of the work proceed in accordance with the documents approved for the building permit. Upon completion of the work, I shall submit a final report as to the satisfactory completion of the above mentioned portion of the work. Signature and Seal of registered professional: 410 ,0Vi OF afq REIGATE tp ELECTRICAL No. 47531 �� ,' 8 /-•4:41141 " T e4iI 4 HI444i vii 54efly, I � F t W; A kta 1301 usivI $.001•, M ..MeA mi 02109 161$ P! K0)727-3200 F (617) 727 -S732 SECONDARY CONSTRUCTION CONTROL DOCUMENT (for Professional Engineers /Architects responsible for only a portion of a controlled project) Project Title: Northampton Survival Center Date: 09/01/2010 Project Location: 265 Prospect Street, Northampton, Massachusetts Scope of Project: Alterations and Renovations to the Northampton Survival Center In accordance with the 7th edition Massachusetts State Building Code,780 CMR SECTION 116.0: I, Charles P. Sharples Mass. Registration Number 28940 being a registered professional Engineer /Architect hereby CERTIFY that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: [ ] Entire Project [ ] Architectural [ ] Structural [ X ] Mechanical [ ] Fire Protection [ ] Electrical [ ] Other (specify) for the above named project and that to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all applicable laws for the proposed project. Furthermore, I understand and AGREE that I shall perform the necessary professional services to determine that the above mentioned portions of the work proceed in accordance with the documents approved for the building permit. Upon completion of the work, I shall submit a final report as to the satisfactory completion of the above mentioned portion of the work. Signature and Seal of registered professional: 4T' . " � CHARLES ‘ P. g SHARPLIS .� :8940 '. • rrei It '�✓� f 1 , • RYAN S. HELLWIG, PE • STRUCTURAL ENGINEER • Secondary Construction Control Document September 7, 2010 ��`N OF kts c' Louis Hasbrouck 4 4 . RYAN S. 'r,90., Louis P Building Commissioner v sTRUCruRAL Municipal Office Building No. 37300 ek- 212 Main Street l' � I o Northampton MA 01060 F SSIONAL i Re: Northampton Survival Center 265 Prospect Street Northampton, MA Project: Addition & Renovations Architect: Nelligan White Architects, New York NY General Contractor: D. A. Sullivan & Sons, Northampton MA In accordance with the 7 Edition of the Massachusetts State Building Code (780 CMR) §116, I hereby certify that I have personally prepared the STRUCTURAL design drawings S1 - S3 (dated 8/23/10) for this project. To the best of my knowledge these drawings conform to the applicable provisions of the Code and to accepted engineering practice. I shall personally perform the necessary professional services during construction of that portion of the work shown in the above - mentioned drawing to determine that it satisfies the design intent of said drawings as submitted for the building permit, plus any revisions, including the following: 1. Review, for conformance with the design concept, shop drawings and /or material specification submittals made by the General Contractor; 2. Be present at the site at appropriate intervals during construction to observe and become generally familiar with the progress and quality of the work. I shall also submit to you a final report upon the completion of the this portion of the project. Respectfully, i r " . . Hel i' 5 .E. • 28 ALDRICH STREET • NORTHAMPTON, MA 01060 • • VOICE 413 - 584 -HLWG (4594) • FAX 413 - 584 - HLWFax (4593) • e o giati 4 t N yte 4 0440 4 pat S T i 0•4 A414.44J141a, Row,. 1301 vt•' $o, •, M 0210$1619 Net (60127 -3200 f (617) -5732 CONSTRUCTION CONTROL DOCUMENT Project Title: Northampton Survival Center Date: _August 23, 2010 Project Location: 265 Prospect Street Northampton MA 01060 Scope of Project: Renovation and Administration Addition for Food Distribution Facility In accordance with the section 116.0 - 116.4.2 of the 7 edition Massachusetts State Building Code: I, BRUCE G. NELLIGAN Mass. Registration Number 11158 being a registered professional Engineer /Architect hereby CERTIFY that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: [ ] Entire Project [ X ] Architectural [ ] Structural [ ] Mechanical [ ] Fire Protection [ ] Electrical [ ] Other (specify) for the above named project and that to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all applicable laws for the proposed project. Furthermore, I understand and AGREE that I shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved by the building permit and shall be responsible for the following as specified in section 116.2.2: 1. Review of shop drawings, samples and other submittals of the contractor as required by the construction contract documents as submitted for the building permit, and approval for the conformance to the design concept. 2. Review and approval of the quality control procuedures for all code - required controlled materials. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine, in general, if the work is being performed in a manner consistent with the construction documents. I shall submit periodically, in a form acceptable to the building official, a progress report together with pertinent comments. Upon completion of the work, I shall submit to the building official a final report as to the satisfactory completion and readiness of the project occupancy. ,oRED gR Signature and Seal of registered professional: ` G. N f m No. : z N N� �R . • Cf ir 1 ' Versionl.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 0 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 /t 1 se- "-Mu.) PA C /Peg Mitrt.t. enr- re /11/1 Lot L as Owner of the subject property eEn. - 'Z i in/c hereby authorize Mark Sullivan to act on : -half, in all matters relative to work authorized by this building permit application. viii Pat C • sip I C6, 70/6 Signature of Owner /liiiMh kt 7b V S Kv/ ✓/f=. CW7./7e /) l iV[, Date Mark Sullivan , 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. Mark Sullivan Print Name � , 310 Signature of Owner / ent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Mark Sullivan CS 53667 License Number 82 -84 North Street Northampton, MA 01060 11/19/2011 Address 7 Expiration Date / 7l t (413) 584 - 0310 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 ® No 0 Version1.7 Commercial Building Permit May 15, 2000 � eriAH /T62 S�,ev / V4L Gi ti e 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: IYl1..144N W III r£ iltal t rf LT& PUG Not A icable ❑ Name (Registrant): 2D ;� 40 SVAEET Woo WAX, Ply /DO /t Registration Number Addres 11/51 "10/14diegi:t0.8 (212) 675 -0500 Expiration Date S / ature Telephone 3 • 3/. // 9.2 Registered Professional Engineer(s): Lindgren & Sharples, PC Mechanical Name Area of Responsibility 435 Cottage Street Springfield, MA 01104 -4005 28940 Address Registration Number (413) 732 - 4336 4/J,/2 aI Z Signature Telephone Expiration Date Lindgren & Sharples, PC Electrical Name Area of Responsibility 435 Cottage Street Springfield, MA 01104 -4005 47531 Addres Registra •0n Num r (413) 732 -4336 /30 2o /2— Signature Telephone Expiration Date Ryan Hellwig, PE Structural Name Area of Responsibility 28 Aldrich Street Northampton, MA 01060 '3' 7 3e"e' 5 " Address Registration Number (413) 584 -4594 6,/,; Signature , Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor DA Sullivan & Sons, Inc. Not Applicable ❑ Company Name: Mark Sullivan Responsible In Charge of Construction 82 -84 North Street Northampton, MA 01060 Address (413) 584-0310 Signature Telephone Versionl.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by ( SE r kril u.) >: D Building Department Lot Size JJJ 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 0 DONT KNOW 0 YES O IF YES, date issued: 08/05/2010 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book 10285 Page 103 and /or Document # 00018863 B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO i 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 0 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 Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Versionl.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 0 Demolition ❑ Repairs 17 Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description Addition/renovation to existing one story masonry/wood- framed building. 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 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 p Specify: Public distribution of food, food storage, administrative offices S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: B & M Proposed Use Group: B & M 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) 1 5t 3,976 1 4,914 2 nd 2 nd 3 rd 3 rd 4 th 4 Total Area (sf) 3,976 Total Proposed New Construction (sf) 4,914 Total Height (ft) 13 Total Height ft 16 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public p Private ❑ Zone Outside Flood Zone 51 Municipal p On site disposal system ❑ • • • Versionl.7 Commercial Building Permit May 15, 2000 Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit - 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413- 587 -1240 Fax 413- 587 -1272 Piot/Site Plans Other Specify 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: This section to be completed by office Northampton Survival Center SEF 2 0 2010 Ma Lot Unit 265 Prospect Street Northampton, MA 01060 Zone Overlay District ' h am Elm SL. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Northampton Survival Center ,' j!G • 265 Prospect Street Name (Print) if LIW'1 S se twA� / ?rep / JC.tt Current Mailing Address: Pa (413) 586-6564 Signature Pit S, Telephone 2.2 Authorized Agent: DA Sullivan & Sons, Inc. 82 -84 North Street Name (Print) Current Mailing Address: 7 (413) 584 -0310 Signature ' T e l ephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building $607,000.00 (a) Building Permit Fee 2. Electrical $65,000.00 (b) Estimated Total Cost of Construction from (6) 3. Plumbing $35,000.00 Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection $93,000.00 6. Total = (1 + 3 + /+ 5) 1$00, GO.. p0 Check Number „---- /- /I f This Section For Official Use Only #' wilding Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date 1 File # BP- 2011 -0248 APPLICANT /CONTACT PERSON D A SULLIVAN & SONS INC ADDRESS/PHONE 82 NORTH ST NORTHAMPTON (413) 584 -0310 PROPERTY LOCATION 265 PROSPECT ST - SURVIVAL CENTER MAP 24C PARCEL 013 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Cf Typeof Construction: ADDITION /RENOVATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 53667 3 sets of Plans / Plot Plan LtL _ 1 • THE FALLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF MATION PRESENTED: V 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 f 11/13/ 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. 265 PROSPECT ST - SURVIVAL CENTER BP- 2011 -0248 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Biock: 24C - 013 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ADDITION BUILDING PERMIT Permit # BP- 2011 -0248 Project # JS- 2010- 001546 Est. Cost: $800000.00 Fee: $0.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: D A SULLIVAN & SONS INC 53667 Lot Size(sq. ft.): 43995.60 Owner: NORTHAMPTON CITY OF 7oninn. UR1 Q0)/ A nlicant: n A SULLI \ /AN R SONS INC AT: 265 PROSPECT ST - SURVIVAL CENTER Applicant Address: Phone: Insurance: 82 NORTH ST (413) 584 - 0310 Workers Compensation NORTHAMPTONMA01060 ISSUED ON:11/23/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:ADDITION /RENOVATION POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring P.W. Building Inspector ?'l 1.1/ ,// Si Vt v i [U I 1 . -4 Underground: / i -i ('..,Service: Meter: �1 Footings: Rough —1/ / Rough: / - 7 /0 House # Foundation: R fJ Driveway Final: Final:3 Ai _p fi nal: ,/ /// R e ranter M 1b,"g. W , ` d 4 g 1� Gas: Fire Departme y �! /V Fireplace /Chimney: • '"�' • � _ -- - Rough: i �'`, Oil: Insulation: � ' /4Ni ail" Final:3 f f A smoke: � r ($ / r/ ,� 1641' c y4 Final: — g l tC !' -' 1 �N ' THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. J' t CO 30 viers 4t-IF 1 t r05 0S --t'( �14/- ' i' Certificate of Occu • anc �I' � £ /4 � ' • nature: FeeType: Date Paid: Amount: Building 11/23/2010 0:00:00 $0.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 4 K1.3 Louis Hasbrouck — Building Commissioner ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDII'YYY) 07/07/2010 PRODUCER 413. 586.0111 FAX 413.586.6481 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Webber & Grinnel1 Ins. Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 8 North Kin Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Northampton, MA 01060 INSURERS AFFORDING COVERAGE NAIC # INSURED D A Sullivan & Sons Inc INSURER A: Acadia Insurance Company 82 -84 North St INSURER B: A.I.M. Mutual Northampton, MA 01060 INSURER C: Darwin Select Ins. Co. INSURER D'. INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ' SR IN ADDL DATE EFFECTIVE Y) POLICY T (MINDDP R IWY) N ADD 'L TYPE OF INSURANCE POLICY NUMBER LIMBS GENERAL LIABILITY CPA130002422 07/01/2010 07/01/2011 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ 300,000 CLAIMS MADE X OCCUR MED EXP (My one person) $ 15,000 A PERSONAL & ADV INJURY _ $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 n POLICY n jEC n LOC AUTOMOBILE LIABILrrY MAA130002621 07/01/2010 07/01/2011 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 X ALL OWNED AUTOS BODILY INJURY $ A SCHEDULED AUTOS (Per person) — X HIRED AUTOS BODILY INJURY $ X NON -OWNED AUTOS (Per occident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS IUMBRELLA LIABILITY CUA130002722 07/01/2010 07/01/2011 EACH OCCURRENCE $ 10, 000,000 OCCUR CLAIMS MADE AGGREGATE _ $ 10, 000, 000 A $ DEDUCTIBLE $ X RETENTION $ 0 $ WORKERS COMPENSATION MCC2000093012010 07/01/2010 07/01/2011 X TORY LIM ER AND EMPLOYERS' LIABILITY B AN PROPRIETOR/PARTNER/EXECUTIVE Y E1- EACH ACCIDENT $ 500,000 (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ 500,000 If yes. describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 OTM 03043363 01/07/2010 01/07/2011 Limit: Si, 000, 000 /$500,000 C Pro Liability Per Claim Ded: $ 10,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS 'VEHICLES' EXCLUSIONS ADDED BY ENDORSEMENT 1 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 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. INFORMATION PURPOSES AUTHORIZED REPRESENTATIVE Richard Webber, CIC/VICKI ACORD 25 (2009/01) ®1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD s. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statue, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the forgoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees, However the owner of a dwelling house having not more that three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer ". MGL chapter 152 section §25(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152 section §25(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contractin • authori ." Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificates(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the Members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self- insured companies should enter their self - insurance license number on the appropriate line. City or Towns Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit /license number which will be used as a reference number. In addition, an applicant that must submit multiple permit /license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 phone #: (617) 727 -4900 ext. 406 or 1- 877 - MASSAFE fax #: (617) 727 -7749 Revised 11 -22 -06 www.mass.gov /dia " The Commonwealth of Massachusetts it� u , Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Mass. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual) : b. A • J Wit 'i Can `, St, �S Inc . Address: $ a • i LI 1\1 b (T Cr • City /State /Zip: No( a.nlbn , MA o1oto o Phone #:41 -5Rs -1. 6310 Are you an employer? Check the appropriate box: Type of project (required): L 1 am an employer with 3 4. L I am a general contractor and I 6. r . New construction employees (full and/or part time).* have hired the sub - contractors 7. Yltemodeling 2. L I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub - contractors have 8. ' i Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. $ 9. ✓Building addition required] 5._i We are a corporation and its 10. C Electrical repairs or additions 3. L I am a homeowner doing all work officers have exercised their 11. J Plumbing repairs or additions myself [No workers' comp. right of exemption perm MGL insurance required] t c. 152, § 1(4), and we have no 12. ❑ Roof repairs employees. [no workers' comp. insurance required.] 13. L Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contactors that check this box must attach an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have em 4 lo ees, the must • rovide their workers' coml. s olic 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: P('Z(n f'(Iui uc0 Policy # or Self -ins. Lic. #: 1Y1C.0 arDOc d l 331 0201 t] Expiration Date: 41 I 1 ab 1 1 Job Site Address: a to 5 1 fbSF.ck 9, . City /State /Zip:.o(}WImpn, DIA Omit) o 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 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 $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjuty that the information provided above is true and correct. Signature: l ,S4 Date: 9•,20 Ib Print Name: tNIAC -. G. Ju311: Y&r' Phone #: A-I13 %4 • 7:).31b 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 Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact person: Phone #: Official Receipt for Recording in: fleepshire County Registry of Deeds 33 King St. Nartham:ton, Massachusetts 01060 Issued To: ATTY PURIM KRELL SOURKE 413-386 -22 Recording fees Docim ent Recording Description Number look/Page Mount DELIS 00018863 10285 103 175.00 NORTMNR'i0M SURVIVAL CENT $75.D0 Collected Mounts Payment Type Amount Check 760 115.00 w~y l75'00 Total Received : 176.00 Less Total Recordings: 175.00 Change Due 1.00 That* You NARIAINIE DOOR - Register of Deeds Sy: Kimberly M Receipt, Date Tiss 0226225 09/02/2010 01:57p Reprinted By: Kimberly N Reprinted On: 09/02/2010 01:57p £0/T0 39t/d 3?iday ,l b1'ZZ985£Th 50 :0T OT0Z /7t i t 09/02/2010 14:05 4135862244 MKSOURKE PAGE 03/03 • Zoning Board of Appeals - Decision City of Northampton Hearing No.: ZBA-2010-0033 Date: August 5, 2010 MINUTES 0? MEETING: Available In the Office of Planning & Davelopment • 1, Carolyn Misch, as agent to the Zoning Board of Appeals, earthy that this is a true end accurate decision made by the Zoning Board end certify that a copy of this and all plans have been tiled with the Board and the City Clerk on the date above. 1 Certify that a copy of this . _ ". n has been mailed to the Owner and Applicant • 1, ill'. 41 NOTICE OF APPEAL • An appeal from the decision of the Zoning Board may be made by any person aggrieved and pursuant to MQL Chapt 40A, Section 17 as amended, within (.20) days (30 days for residential Finding) after the data of the fling of th/S deCislon wldr the City Clerk The data of filing is Wed above. Such appeal may be made to the Hampshire Superior Court with a carefted copy of the appeal sent to the City Clerk of Northampton. • AUG - 5 2010 ,TJ • CITY CLERKS OFFICE NORTHAMPTON, MA 01060 August 26, 2010 I, Wendy Mazza, City Clerk of the City of Northampton, hereby certify that the above Decision of the Northampton Zoning Board of Appeals was filed in the Office of the City Clerk on August 5, 2010, that twenty days have elapsed s ce such filing and that no appeal has been fit in this matter. 72.113 • Attest: [A , • City Clerk City of Northampton • • • • • QeoTMSS 2010 Das Landers municipal Solutions, inc. ATTEST: HAMPSHIRE, M ,REtIIBTER • MARIANNE L. DONOHUE 09/02/2010 14:05 4135862244 MKBOURKE PAGE 02/03 Zoning Board of Appeals - Decision City of Northampton • • Hearing No.: ZBA -2010 -0033 Date: August 5, 2010 • • F rPitiCATION TYPE: I SUBMISSION DATA ComMen*a1 Finding 6 JR?�010 • Applicant's Name: Owner's Name: NAME NAME Bk: 10286Pg: 103 Pogo: 1 of 2 . NORTHAMPTON SURVIVAL CENTER NORTHAMPTON CITY OF Recorded: 09/02/2010 01:07 PM ADDRESS: • ADDRESS 265 PROSEPCT ST • 210 Main Street TOWN; STATE ZIP CODE: TOWIt - $1ATL tee CDDE: ' NORTHAMPTON MA • 01060 NORTHAMPTON MA _ 01060 PHONE NO.: FAX NO.: PHONE NO.: FAX N0.; (4131 -63 4 0 EMAJL ADDRESS: EMAIL ADDRESS: Site Information: Surveyor's Name: STREET N0. ESTE ZONSIQ COMPANY RAMC • 265 PROSPECT ST uRB(100)/ TOM ACTION TAKEN; ADDRESS: NORTHAMPTON MA 01080 Approved aN Conditions MAN, !FLOCK LOT; MAP DATE: SECTION OF BYLAW 24C 013 1 001 1 ChapL 350 -13 (1) (D). P, Istrng Tote* STYE: I ZIP CODE Sack 1141g4k Nonconforming Shucks= or Uses Maybe . Changett, attended Or NJtatd with s PHONE NO.: PAX NO.: Finding from the Zoning Board of Appeals. EMALADORES£ NATURE OF PROPOSED WORK EXPANSION • HAND9M': CONDmON OF APPROVAL 1) SuivJva/ Canter sign be moved to the south side of the driveway IF it can obtain necessary permits, and in accordance with the SJta Plan labeled C100 and dated 6128/2010 and showing the panting setback 10 feet from the front property boundary and with the front hedge kurdawrp.d hr accordance with • July 16, 2010 latter from the Survival Center. FINDINGS: The Zoning Board of Appeals voted unanimously to approve the requested finding, on the basis that the use Is no more detrimental to the neighborhood 11 was approved with the condition that the Survival Canter sign be moved to the south side of the driveway IF it can obtain necessary permit!, and in accordance with the Site Plan labeled C100 and dated 6/29/2010 and showing the parking setback 10 feet from the front property boundary and with the front hedge landscaped to accordance with a July It 2010 letter from the Survival Center. COULD NOT DEROGATE EECM15E: • PLP 0 OEADLIt1E: MAUNG DATE: FEARING CONTRJUEO DATE DEO$$IOM DRAFY aT APPEAL DATE: 6122/2010 7/17/2010 6/5~2010 - REFERRALS ti DATE HEANWG DEADLINE OATS - HEARING CLOSE DATE FINAL SIGNING 9Y: APPEAL DEMUfI 7/10/2010 8/26/2010 7/22/2010 815>2010 6/25/2010 - FIasT ADVERTISING DA1E HEART DATE VOTING bAYE DECISION DATE: 7/8/2010 7112/2010 • 7/22/2010 111512010 SECOND ADVENTISM OATS: HEARING TAM VOTING mamas; DECISION DEADLINE 711512010 6:1 0 Pit _ a10 MEMBERS PRESENT: VOT 9/30/2010 . Malcelrnr 8.E Smith vDtee to Gant • David Bloomberg votes to Grant Sam Northrup votes to Grant Bob Rldd►s votes to no action needed • 1fO'l arStAL EY SECONDED SY: voTi colon co DLDlstctt • Sara Northrup I N aicolm 8.E Smith 3.0 I Granted et C nd1 ons GeoTMS® 2010 Des Laurier' Municipal Solutions, Inc. • • r n rf,_. Zll • File No. i v s ; / i`,C +G � r l > '' ---./ f"r� C f ( a J p ^s � L ��a, �,Rlase� .gr p t all information and return this form to the Building Inspector's O . �f i .. th the $15 filing fee (check or money order) payable to the City of Northampton 1. Name of Applicant: T ! is. r - titzvaJ46._ cori Address: Telephone: 2. Owner of Property: Cf J Address: 6 Telephone: 3. Status of Applicant: Owner Contract Purchaser Lessee X.. Other (explain) 4. Job Location: ti ... 5. Existing Use of Structure/ Property: C-(iP e / T e rni'r17' 7:=-7, p dip - zlr -- .s46 6. Description of Proposed Use/Work/Project /Occupation: (Use additional sheets if necessary): d& '. 11 • 0/ 1 /fA i l f .CFAATZ 41 & / ) iffbtleArlO 0 S eg676 S�rJf 7. Attached Plans: Sketch Plan X Site Plan X, Engineered /Surveyed Plans X 8. Has a Special Permit/Variance /Finding ever been issued for /on the site? NO DONT KNOW x YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES: enter Book Page and /or Document # 9.Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , date issued: (Form Continues On Other Side) 81' WA Documentsl FORMSbriginal \Buiiding- Inspector\Zoning- Permit - Application- Passive:doc 004 ' File # MP- 2010 -0085 APPLICANT /CONTACT PERSON NORTHAMPTON CITY OF ADDRESS/PHONE 210 Main Street PROPERTY LQ • , Z05.PRospEcT ST - SURVIVAL CENTER A ; Sc P44R ; L. oil QO1 ZONE TRB(i00)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out /E-L r Fee Paid WO' .- _ ■ Tyeof Construction: ZPA - EXPANSION • New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan M /214/1/b6° THE FOLLOWIN AC ON HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRE NTED 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 BO ERMIT REQUIRED UNDER: § " 1 r j C� —8 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 �6∎∎ - - 47. ) Fl h d Signature of Building fficial Date Sn g 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 the Office of Planning & Development for more information.