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32A-138 Louis Hasbrouck ••=1�11•010=° From: Louis Hasbrouck Sent: Tuesday, June 12, 2012 12:19 PM To: 'Jan' Co: 'Ted Parker'�{�hadeoK8iUar . Subject: RE: Fitzwilly's building permit ]an, Also, be sure to contact the police department and DPViii it necessary to secure permits it you set up oh or work overche Louis Hasbrouck. 8uiid|ng Commissioner City of Northampton Town of Williamsburg 212 ��ain Eiinedt Northam ptmn MA 01080 (413)5B7-124O From: Louis Hasbrouck Sent: Tuesday, June 12, 2012 12:13 PM To: 'Jan' Cc: Ted Parker Subject: RE: Fitzwilly's building permit ]an, You may proceed with the work. Please keep my apprised of the situation and submit the complete permit application as soon as possible. Thanks. Louis Hasbrouck Building Commissioner City of Northampton Town of Williamsburg 212 Main Street Northampton, k8AO1OGO (413)5S7-124O From: Jan [moiho:jdreyerVbhvctvoofinQ.com] Sent: Tuesday, June 12, 2012 12:04 PM To: Louis Hasbrouck Cc: Ted Parker Subject: RE: Fitzwilly's building permit Louis, Because the building's roof is actively leaking, we hereby apply for permission to begin work immediately, based upon the provisions of IBC section 105.2.1, which provides for the commencement of work under emergency circumstances. Thank you. Jan Dreyer J. D. Rivet & Co., Inc. NEosachusettN - De1)..11 of Pub Ile S.ifct:, • zki Board of Built lin! Re•wl.itionN iud . Construction Supervisor License License: CS 50230 JAN N DREYER . . 44 LAKESIDE DR MONSON, MA 01057 E.r.piration. 71212012 -- ( T 2950 6 Ac O R ® CERTIFICATE OF LIABILITY INSURANCE DATE 04 /30/ DDIYYYY) 4 4...../ --- 04/30f2012 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 1- 312 - 704 -0100 CONTACT Certificate Issuance Team Arthur J. Gallagher Risk Management Services, Inc. PHONE FAX (AJC No. Fxt): (A/C,No): 312 - 803 -7443 300 South Riverside Plaza ADDRESS: Chi Certificatee@A.3G.com Suite 1900 Chicago, IL 60606 INSURER(S) AFFORDING COVERAGE NAIC INSURERA: ARCH INS CO 11150 INSURED INSURER B: AMRRICAN GUAR & LIAB INS 26247 J.D. Rivet & Co., Inc. INSURER C 1635 Page Blvd. INSURER D: Springfield, MA 01104 -1752 INSURERS: , INSURER F : COVERAGES CERTIFICATE NUMBER: 26947671 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 T YPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR W1r). POLICY NUMBER IMM/DD/YYYY) IMWDD1YYYY) A GENERAL LIABILITY ZAGLB9155800 05/01/12 05/01/13 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 300, 000 PREMISES (Ea ocavence) $ CLAIMS - MADE I X OCCUR MED EXP (Any one person) $ 10,000 X 5,000,000 All Projects PERSONAL &ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT_ AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ 2,000,000 POLICY X PRO- LOC _ $ A AUTOMOBILE LIABILITY ZACAT9138100 05/01/12 05/01/13 COMBINEDSINGLEUMIT 1,000,000 (Ea accident) $ X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ _ HIRED AUTOS _ AUTOS (Per acccident) Physical Damage $ 1, 000 Comp/Cot. B X UMBRELLA LIAB X OCCUR AUC- 9244241 -00 05/01/12 05/01/13 EACH OCCURRENC $ 5,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $ 5,000,000 DED I ( RETENTION $ 10,000 $ A WORKERS COMPENSATION ZAWCI9271 05/01/11 05/01/13 I WCSTATU + 10TH AND EMPLOYERS' LLIUMUTY TORY I NITS I FR Y � / - I� N ANY PROPRIETOR/PARTNER/EXECUTIVE ��— N / A E.L EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? I N 1 (Mandatory in NH) E.L. DISEASE _EA EMPLOYEE $ 1,000,000 If yes, describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) e a ° 4 4 4 ° e 1 Jo: L° t t c 4 5 - L44-I6V. - ci+0.4.(11ys Z 3 .. tlt\ S'rce -1 /`.brtrn(ry 9 014 Olds CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Coverage THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD bhargavchi 26947671 The Commonwealth of Massachusetts • Department of Industrial Accidents B'ii ; r ; Office of Investigations 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): J. D. Rivet & Co., Inc. Address: 1635 Page Boulevard City /State /Zip: Springfield, MA 01104 Phone #: (413) 543 -5660 Are you an employer? Check the appropriate box: Type of project (required): 1. I am a employer with 50 4. nI am a general contractor and I 6. El New construction employees (full and/or part- time).* have hired the sub - contractors 2. E1 T am a sole proprietor or partner- listed on the attached sheet. $ 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. El Demolition working for me in any capacity. workers' comp. insurance. 9. 0 Building addition • [No workers' comp. insurance 5. []We are a corporation and its • required.] officers have exercised their 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.19 Roof repairs insurance required.] t 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. tContractors that check this box must attached an additional sheet showing the name of the sub - contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Arch Insurance Company Policy # or Self -ins. Lic. #: /( ZAWCI92335300 Expiration Date: 5/1/2013 Job Site Address: 01 JJ"raN t / vlO r (� *Alp t City/State /Zip: ∎ A•i . Q(Q I 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 t wins and penalties of perjury that the information provided above is true and correct. Signatu • • .P �., Date: a yil f/ Z Phone #: (413) 5' - 5660 Official us 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 ® No O SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, T44 t>e6 ` f A�}-� J ' -H,' 1" 5/ (of ? , as Owner of the subject property hereby authorize 3 -E (612._ o 1 G-1 4 Co -) t N • to act on my behalf, i . I ma ers relative to work authorized by this building permit application. I 1 () (I E 2 Signature of Owner Date I, - 1 - p4.1 , asp44 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 ›g8t/ !t Date _ / , SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder 1 SoZ30 . License Number C— PKKE -Set A be-NtE 07. 21. 2012— Address Expiration Date MO N S-o N NIA- o O S7 4-43 Sc4-3 se 6 Signature a —ip 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 42 No 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): 4isegT L T P. E. 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 • Ri' T -4 co ' ) 1 IJc • Not Applicable ❑ Company Name: z Responsible In Charge of Construction Co. &X 6(o6g (nib PrN O k PAA °(1S! Address 4(3 SLf3 s66a Signature Telephone fi Versionl.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be tilled 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 0 DONT KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® 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 ® DON'T KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ,Date Issued: C. Do any signs exist on the property? YES Q NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO er 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 a 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 ❑ Repairs [0' Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofingir Change of Use ❑ Other ❑ Brief Description Enter a brief description here. R ROVE Roo f I N6t Tb K . Of Proposed Work: 1 hi S T L{ N &1n/ CON T I N W7 tr&S i2 2.D emg,g,Ar! ftNt. tr . E- ME7 SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A � ❑ A-4 ❑ A -5 ❑ 1B ❑ B Business 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F -1 0 F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 0 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 Co7 fir. ROOF /ek- ( O i 4- tfr. BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) 1 St 1 st 2' 2nd 3rd 3 rd 4 4 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❑ -- . . Version1.7 Commercial Building Permit May 15, 2000 r. � Department use only ity of Northampton Status of Permit Am y 3 Cu12 ilding Department C urb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability L_,____„_.-___.._.___ —.^ .. Room 100 Water/Well Availability DEPT. OF BUILDING INSPECTIONS NORTHAMPTON MA 01060 N h ampton, 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, 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 `1tTZW lt-t -y 's l Map Lot Unit 2 3 A�tPr� ,..<1 t i C2,1 " 3/ F1 4 /his S� • J Zone Overlay District N92TH 7 P7 oN Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: GHA I SA 601 31 c-A.YIPv> PLAZA PA T+ Name (Print) g op . e. PAL v , ,, Current Mailing Address: 141w Lei M ft 0 1 p ;y Signature ...D P.Aenit___„- Telephone 'TI 3• �i�i (o 0 l 3 Z - 1 2.2 Authorized Agent: n O _ Name (Print) � f Ar4 t tE 6/2_/.T. , t -1\I ST 4. Cp . Current Mailing Address: P C' • rev 7C t O 6 8' 111 INDIA 02c4+ MP- o (ti Signature Telephone 4- t3 5C+3 - S66 O SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building . 7, o O a (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) 7 / coo Check Number 'iT 9/ 0 y6. i L This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File # BP- 2012 -1112 APPLICANT /CONTACT PERSON J D RIVET & CO INC ADDRESS/PHONE P 0 BOX 51068 INDIAN ORCHARD (413) 543 -5660 PROPERTY LOCATION 23 MAIN ST MAP 32A PARCEL 138 000 ZONE CB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out i l f( $4 Fee Paid Tyeof Construction: REMOVE ROOF TO DECK,NEW R -20 INSULATION,MEMBRANE & EDGE METAL New Construction de G U Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: {' L Owner/ Statement or License 050230 f „ 3 sets of Plans / Plot Plan �f THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: proved 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 De olition Delay Sig e 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. 23 MAIN ST BP- 2012 -1112 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 138 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit # BP- 2012 -1112 Project # JS- 2012 - 001900 Est. Cost: $77000.00 Fee: $462.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: J D RIVET & CO INC 050230 Lot Size(sq. ft.): Owner: CHAMISA CORPORATION TO: HAMPSHIRE PROPERTY GROUP Zoning: CB(100)/ Applicant: J D RIVET & CO INC AT: 23 MAIN ST Applicant Address: Phone: Insurance: P 0 BOX 51068 (413) 543 - 5660 Workers Compensation INDIAN ORCHARDMA01151 ISSUED ON:6/15/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: REMOVE ROOF TO DECK,NEW R -20 INSULATION,MEMBRANE & EDGE METAL - ENGINEERING DOUMENTS BEFORE FINAL 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 6/15/2012 0:00:00 $462.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner