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24C-005 (7) CITY OF NORTHAMPTON Construction Debris Affidavit In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work covered by a Building Permit shall be disposed of in a properly licensed disposal facility, as defined by M.G.L. c. 111 § 150A. Address of Work: 2g5 ? 'c pew- +reek 1306,,i-Lotsiiet.) The-debris will be transported by: (OM plot? A5 pc,Sk(.- The debris will be received at: F9w I c-r-- tuesierN Recl,c-L Zb 6ra- Mme, Signature of Permit Applicant !� Date /Z /3 w Building Permit Number: Jun 07 2013 2:51 PM HP Fax page 1 ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID OATEINN/DDIVYYY) CREST-1 06/07/13 PRODUCER THIS'CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Towne Insurance Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 100 Main Street ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. Agawam MA 01001 Phone:413-786-3535 INSURERS AFFORDING COVERAGE NAIC INSURED INSURER A: The Travelers INSURER B: AI»Assoaiat ad Industries of N Crestyiew Construction & INSURER C: Trucking, Inc. and Ridgeline 25 Indubtrial Road INSURER D: Southwick MA 01077 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. LAWL TTRR INSRD TYPE OF INSURANCE POLICY NUMBER DALTEYjMBWD YY) PDATE M TIR METE GENERAL LIABILITY EACH OCCURRENCE $1000000 A X COMMERCIAL GENERAL LIAR ILRY 1660-337X281ATIL-12 07/18/12 07/18/13 PREEMISESIECEocatrence) $100000 CLAIMS MADE X OCCUR MED EXP(Any one person) $5 000 PERSONAL&ADVINJURY $1000000 GENERAL AGGREGATE $2000000 SENt AGGREGATE LIvIIT APPLIES PER: PRODUCTS-COMP/OP AOG $2000000 POLICY JECT n LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1000000 A X ANY AUTO 3A6128N518-12SEL 07/02/12 07/02/13 (Eeeccidern) ALL OWNED AUTOS BODILY INJURY A X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ ¢ PROPERTY DAMAGE $ (Per accident) GARAGE U Ml1LITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE 5 IOCCUR I CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND X ITORYLIMITS ER 3 EMPLOYERS'uABILITY WMZ8003011012013 04/15/13 04/15/14 E.L.EACH ACCIDENT $100000 ANY PROPRIETORJPARTNERJEXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $100000 If yes describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500000 OTHER DESCRIPTION OP OPERATIONS/LOCATIONS!VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION FORREST SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL Forrest Devine IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,RS AGENTS OR 20 Hartland Hollow Road Granville MA 01034 REPRESENTA ES. AUTHO ED t2277.4 Lis ACORD 25(2001108) ®ACORD CORPORATION 1988 .; The Commonwealth of Massachusetts Department of Industrial Accidents • '' - Office of Investigations , 452 -•� 600 Washington Street " --I~= Boston,MA 02111 `` . www.mass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrganizationandividuaI):_C..< . *u\Q-t.JJ C ncv Nkt`ii�..1/41 r\ Address: -'S dv'SkC∎C7�\ ?d. City/State/Zip: a,` �r � tC o\c hone#: L (,, Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 1 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors ❑ I am a sole proprietor or partner- 2. listed on the attached sheet. 7: ❑Remodeling ship and have no employees These sub-contractors have 8. i Demolition working for me in any capacity. employees and have workers' g Y P tY $ 9. „Building addition [No workers'comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have their 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work ave exercised ❑ myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t C. 152, §I(4),and we have no 13.0 Other employees. [No workers' 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: /-s..„v, ( `Q C).•\ Policy#or Self-ins. Lic.#: (( Z7 t —���►� ' on Date: L4 1,s\1.4 Job Site Address: 7 `1VVd` E.C.oV `S" " City/State/Zip: 1 fz,T- f\0..6 r. ay.-W' -,0063 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 unde th• ,•ins and penalti� pe:lay that the information provided above is true and correct Si•nature?� ,/fi_/ . ,i ✓ ...; -- Date: Phone#: Av.- 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, __.__....._....._ ______ _...M. . ,as Owner of the subject property hereby authorize`__..... .. act on my behalf, in all matters relative to work authorized by this building permit application. _ __ Signature of Owner Date 1, . ,kl4 ,,_,; ,-e ed ._.__... - as Owner/Authorized Agent hereby declare that the atements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the painsandpenalties of perjury. Print Name .—. _ __ Sig er gen Date ,1 A—i.A4 1 C,- 0 / SECTION 12-CONSTRUCTION.SERVICES 1 10.1 Licensed Construction Supervisor: 3 Not Applicable 1:1 Name of License Holder:'......42 -(/r n.� .--- - 0117779 ��� License Number 70 47 AeP_7Zdery _ -../4°__Pleft_010.3'e 7/-5// -° r Addres• Expiration Date Signature ' ' Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8)) 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 • Version1.7 Commercial Building Permit May 15,2000 s 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 ENSLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): s """" "M°"""' .._ .__.—__.________ Registration Number Address , L_. 1/13 73! q o b Expiration Date Signature Telephone j� 9.2 Registered Professional Engineer(s): Name Area of Responsibility i Address Registration Number W f Signature Telephone Expiration Date Name Area of Responsibility Address _ Registration Number I i Signature Telephone Expiration Date I Name _._ _._ w _. N Area of Responsibility M-. . Address Registration Number t I Signature Telephone Expiration Date Name Area of Responsibility H___. Address Registration Number . i Signature Telephone Expiration Date 9.3 General Contractor - e ' e fj' �cP _ v _ Not Applicable ❑J_ Company Name: f Responsible In Charge of Construction_ Zo . �._._.__ ___ � ®LLB Addrer y3?r1 . Signa ure Telephone Version1.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed` Required by Zoning , This column to lie filled in by Building Department Lot Size L. _. _ __..�_ Frontage _ ._... .... Setbacks Front 'z Side L: R:€i L::i t ` i R:i1Z1 1 i?Sii !I-7 t s I Rear ---, Building Height I ['11 1 Bldg. Square Footage _ _�...t % r a _. Open Space Footage .,,,,,, , % °-- ©�'� 1 i (Lot area minus bldg&paved ) 1 --•---- parking) #of Parking Spaces t Fill: $ , (volume&Location) — * —' * . 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 YES 0 IF YES: enter Book ' Page' 1 and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES C 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 )2; IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,gradin•,excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES (3 NO , ' IF YES,then a Northampton Storm Water Management Permit from the DPW is required. • • Version1.7 Commercial Buildin_Permit May 15,2000 `'t.' - -_ d a S "Attl r � __ City of Northampton Building Department ` `® � EJUN 1 212 Main Street °` 'r 32013 Room 100 § ` �' Northampton, MA 01060 _E DEPT OP BUI_DING INSPECT�p�q ", x°t "oRTHAMProN,MA Oa one 13-587-1240 Fax 413-587-12726 -, .6 �,, ", 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 7gf P-oS' X04: 5J' e4 Map Lot Unit 1 .Zone: Overlay District -- ----- I Efm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �+f ._ C31 o r I, ( ;S A-v?__t4e ",. .0-.?!7 icy L ! Name(Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent: F ' 2 L S ._.._!-/ V l a._ __ _ Z© �"�4, 4;`OW_'_`____.. _-.._.,_ Name(Print) Current MailinlinAddress _ �: �-- wwi fle 61(23,7_________ -__.__ --- Signature 41111■0111■._ Telephone 14/3 Z/1'' g',j 2? ? 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 049 i (b)Estimated Total Cost of ---- ---0---00 di!"--"' Construction from(6) 3. Plumbing C ' Building Permit Fee 4. Mechanical(HVAC) __•.__ 5. Fire Protection 20 000- -. __ ___ . .__ 6. Total=(1 +2+3+4+5) Check Number 0496-0 This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date Version1.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE •.■ ' - F Interior Alterations ❑ Existing Wall Signs ❑ Demolition►'o? Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ _. Brief Description Enter a brief description here. 60o/te..{9u9ttA_Qi ._ Of Proposed Work:1 L • i _ tit G S. •: wok.�r,,,_ _ , ,_ w'1--kn 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 I ❑ E Educational ❑ 2B r ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C I ❑ 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 I ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: — S Special Use ❑ Specify: [ I COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: ? _.Q"\ P N.C1,---\ I Proposed Use Group: :--7:7- -".. i�k1,r_•--\ Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):I. _ _ _., SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1st - .�_ ____. 1st _-_„.30 I �\.�'1. . �4 t- x ck 2nd S._ .. ..._'6\a.... 2nd =.... � .s4) __._ _.__.__..1 Total Area(sf) 'ice 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[] File#BP-2013-1203 L APPLICANT/CONTACT PERSON FORREST DEVINE r•-‘'\ IL' ADDRESS/PHONE 20 HARTLAND HOLLOW RD GRANVILLE (413)214-8629 ^o r�∎ C' PROPERTY LOCATION 285 PROSPECT ST MAP 24C PARCEL 005 001 ZONE URB(100)/ p 09S- (L:S,-(, ce THIS SECTION FOR OFFICIAL USE ONLY: I ? �C'J PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out /01-901 $C9 9 cz' Fee Paid Typeof Construction: DEMOLISH WREHOUSE STRUCTURE(FOOTINGS TO REMAIN) New Construction Non Structural interior renovations Addition to Existing, Accessory Structure Building Plans Included: Owner/Statement or License 95779 3 sets of Plans I Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Sign 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. 285 PROSPECT ST BP-2013-1203 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24C-005 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: demolition BUILDING PERMIT Permit# BP-2013-1203 Project# JS-2013-000037 Est. Cost: Fee: $200.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: FORREST DEVINE 95779 Lot Size(sq. ft.): 12240.36 Owner: IB PROPERTY HOLDINGS LLC Zoning:URB(100)/ Applicant: FORREST DEVINE AT: 285 PROSPECT ST Applicant Address: Phone: Insurance: 20 HARTLAND HOLLOW RD (413) 214-8629 GRANVILLEMA01034 ISSUED ON:6/19/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:DEMOLISH WAREHOUSE STRUCTURE (FOOTINGS TO REMAIN) 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 6/19/2013 0:00:00 $200.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner