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23A-068 (2) Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License License: CS 65106 GLEN E LUNDSTROM 36 FLAXFIELD RD DUDLEY, MA 01571 • • Expiration: 9/29/2013 ('onun issioner Tr#: 4333 • 183671 AWRD CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD /YYYY) ,�.. 5/2/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Samantha Scheibel NAME: Commercial Lines - (952) 830 -3000 PHONE 9525630677 FAX 9525630528 (A/C. No. Ext): (A/C, No): Wells Fargo Insurance Services USA, Inc. E -MAIL samantha.scheibel wellsfar o.com ADDRESS: g 4300 MarketPointe Drive, Suite 600 INSURER(S) AFFORDING COVERAGE NAIC # Bloomington, MN 55435 -5455 INSURERA: Westchester Surplus Lines Ins. Co. 10172 INSURED INSURER B: JF Acquisition LLC dba Jones & Frank INSURER C : 1330 Saint Mary's Street INSURER D Suite 210 INSURER E : Raleigh, NC 27605 INSURER F : COVERAGES CERTIFICATE NUMBER: 4282767 REVISION NUMBER: See below 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MM /DD/YYYY) (MM /DD/YYYY) A GENERAL LIABILITY 624179461002 12/18/2011 12/18/2012 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ 1,000,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 25,000 PERSONAL & ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 2,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 POLICY r LOC Deductible $ 25,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) A X UMBRELLA LIAB X OCCUR G24179473002 12/18/2011 12/18 /2012 EACH OCCURRENCE $ 8,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $ 8,000,000 DED RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N TORY LIMITS ER ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The Insurance Company with which this coverage has been placed is not licensed by the State of North Carolina and is not subject to its supervision. In the event of the insolvency of the insurance company, losses under this policy will not be paid by any State insurance guaranty or solvency fund CERTIFICATE HOLDER CANCELLATION City of Northampton SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main Street, Room 100 Northampton, MA 01060 AUTHORIZED REPRESENTATIVE 94 The ACORD name and logo are registered marks of ACORD © 1988 - 2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) To the City Of Northampton Property of : 100 Main St., Florence, MA Lehigh Gas, Owner of the subject property hereby authorize Jones and Frank Petroleum Equipment Specialists, to act on my behalf, in all matters relative to work authorized by this building permit. 4// Client#: 635085 JAMESGGR ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DDNYYY) 5/02/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER g cr USI Ins Sery of MA, Inc I IN gy p, 800 635 -8760 FAx P O Box 920444 E-MAIL (A/C. No): ADDRESS: Needham, MA 02492 INSURER(S) AFFORDING COVERAGE NAIL 1 INSURER A : Travelers Indemnity Company of 25682 INSURED INSURERS Liberty Mutual Ins Companies 65315 James G Grant Co Inc INSURER 28 Wolcott Street INSURER D : P O Box 54 MR9URER E Boston, MA 02137 - etSURERF COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY RECIUIREINENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, 7HE 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. i T YPE OF INSURANCE ADOR_MUBR POLICY NUMSER PCd.1CY EFF POLICY EXP I EMITS L INSR_ D INM/DD/YYYY) unuoo/YYYY) GENERAL LIAeILJTY EEDA,,CyyyyH��ccOCCCSUURRENCE $ COMMERCIAL GENERAL LIABILrr,' PREMISES (Ee p u � $ CLAIMS -MADE OCCUR MED EXP (My one season) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE 5 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 7 POLICY 7 LOC g AUTOMOBILE AS2Z11247235072 02 /10/2012 02/10/2013 ce nzs? ANGLE LIMIT 1,000,000 ANY AUTO BODILY INJURY (Per peen) $ ALL OWNED X SCHEDULED BODILY INJURY (Per accident) $ AUTO X H RED X NSN-O WNED PROPERTY DAMAGE $ AUTOS IPeraccident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE 5 —+ EXCESS LAB CLAIMS-MADE AGGREGATE'. $ DED RETENTIONS $ A WORICERS COMPENSATION 6KUB4887P91611 10/16/2011 10/16/2012 X 'TORY "MRS 1 W AND AND EMPLOYERS' LABILITY OPFlCE E ARTN E ED7 (EC" I Y N N / A EL EACH ACCIDENT 51,000,000 (Mandatory In NH) EL. DISEASE - EA EMPLOYEE $1,000,000 If y, describe under DESCRIPTION OF OPERATIONS below EL DISEASE - POLICY L!LIIT $1,000,000 DESCRIPTION OF OPERATIONS J LOCATIONS 1 VEHICLES (Attach ACORD 101. Additional Remarks Sohsdule, If more spates Is required) Evidence only. CERTIFICATE HOLDER CANCELLATION Jones & Frank SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O. Box 184 ACCORDANCE WITH THE POLICY PROVISIONS. Monson, MA 01057 AUTHORIZED REPRESENTATIVE A ® 1988,2010 ACORD CORPORATION. Ali rights reserved. ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S7213635/M6929916 PXKZP Z abed 09L ,179£L 19 Xed dH NV95:6 Z LOZ ZO 4214 The Commonwealth of Massachusetts �.t Department of Industrial Accidents a LL t. Office of Investigations '-- 600 Washington Street Tr Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): _ Address: City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. I am a employer with 4. El I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub contractors have 8. 5Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. 0 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. Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City /State /Zip: 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 #: 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 0 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 4,i d ..y z S , 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. 5" i 4-4-i-itu 4'e d Signature of Owner Date e 4". '0,"C ° , e--A 51-e V _._, _.__ , 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 ofper 'ur L ,,, ... t ,.. 4 _.. . .., . t � ° l r f � v ..z`.,.t...>a! " ._ Print Name tmos— 512 if Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ �� -� L �,�d C _. ._ 6 ./ 4 6 G Name of License Holder . License Number Addres Expiration Date S Si 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 buil ing permit. Signed Affidavit Attached Yes No 0 JONESI4 OP ID: D5 SR° CERTIFICATE OF LIABILITY INSURANCE DA 05/02/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 336 - 228 -0541 CONTACT Somers - Pardue Insurance NAME: Division of HUB International 336 - 226 -6772 (A/C. N , Ext): FAX No): PO Box 939 E -MAIL Burlington, NC 27216 -0939 ADDRESS: Joseph A. Pardue INSURER(S) AFFORDING COVERAGE NAIC # INSURER A:SelectiVe I ns Co of Southeast INSURED Jones & Frank INSURER B:SeleCtiVe MS. CO. Of SC JF Acquisition LLC DBA 1330 St. Mary's St Suite 210 INSURER C: _ Raleigh, NC 27605 INSURERD INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSR VD POLICY NUMBER (MM /DD/YYYY) (MMIDD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ _ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ CLAIMS -MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ POLICY PRO- LOC $ .IFCT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1000,000 (Ea accident) $ r A X ANY AUTO A 9093210 03/31/12 12/18/12 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS' LIABILITY TORY LIMITS ER Y/ N B ANY PROPRIETOR /PARTNER /EXECUTIVE WC7978091 - MA 03/31/12 12/18/12 E.L. EACH ACCIDENT $ 1,000,000 OFFICER /MEMBER EXCLUDED? N / A — (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION CITYNOI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. Building Dept 212 Main Street Room 100 AUTHORIZED REPRESENTATIVE Northampton, MA 01060 © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 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 EtLOSED 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 R,,egistration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date MS _ Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable n Company Name: Responsible In Charge of Construction Address Signature Telephone • Version1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed Required by .honing This column tore 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 I Fill: (volume & Location) ------ �---°--------- M--- -.-- _._- ---- � •- --�._. A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW / YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 " _... _..._ ._ IF YES: enter Book ' Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES (3( NO 0 IF YES, describe size, type and location: Mj o' / 1 4/ C or ti r F' 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, exc vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 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 d 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 t : a 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 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B - I ft ❑ 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 I ❑ U Utility ❑ Specify: : ®. _ M Mixed Use ❑ Specify s .._e S Special Use ❑ Speci n Specify. F _ u..,. ._�.. �. _, .. e.�____ ___,. �..�..,...�.�,- �....__.e. COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: _______._._.__._ _...__ _ __ ._, _ Proposed Use Group:. _ ._.._m______ _._.._____ ____._.J, Existing Hazard Index 780 CMR 34): ,.., Y__ _ ______ 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 ; 1 2nd _...._._ 2n d .„. W 31-1 3r -_. ____ 4m__._._..._ ..._ __ _ _ __ ._.____ _ 4 m - 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 ❑ Private ❑ Zone _ ,,,,_ _ _ Outside Flood Zone Municipal ❑ On site disposal system E] ,nl ` t-� Version1.7 Commercial Buildin_ Permit Ma 15, 2000 R EC E! v E V �Y Deperfrrle t use City of Northampton Stattas la e x #0 Building Department C • Gut/Dnueway Permlta' 9 212 Main Street Sew�eSept�cAvaifarllf Room 100 ll>�t.E r ll AV lla }h Za a ;, owl OF BUILDING INSPECTIONS orthampton, MA 01060 Two SeYS of StruCturatFta�tS NORDINAPTON.MA 010110 _ _ 1.31101 4 3- 587 -1240 Fax 413 - 587 -1272 Platfsite Pans Oth 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 Pro er Address: This section to be completed by office /g /Al Sr Map Lot Unit r/ /e Bi r M/1 Zone Overlay District _......, z Elm St "District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Le l 211, tr irb �Ct mteU P/IS Name (Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent: L. ,, ;C = w43 t 1... .oars k f ! �_ Name (Print) Current Mailm9 Address Signature �fe../.0/0uC/ vw 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 /021/45 0 This Section For Official Use Only Building Permit Number Date Issued Signature: . Buildin ommissioner /lnspecto of Buildings Date 100 MAIN ST BP-2012-0974 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A - 068 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- 2012 -0974 Project # JS- 2012- 001691 Est. Cost: Fee: $20.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JF ACQUISITION LLC 65106 Lot Size(sq. ft.): 20865.24 Owner: GAS LEHIGH Zoning: GB(100)/ Applicant: JF ACQUISITION LLC AT: 100 MAIN ST Applicant Address: Phone: Insurance: P O BOX 184 WC MONSONMA01057 ISSUED ON:5/9/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: DEMOLISH CANOPY STRUCTURE 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 5/9/2012 0:00:00 $20.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner