35-139 (2) ACORDTM CER IIC� T O� ' [�B�' 1 11�SUENCE
DATE(MM/DD/W)
,. `� .: . -� r. _.- 10/18/04
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Aon Risk services of Texas, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
301 Commerce street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Suite 2101 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Fort worth Tx 76102
COMPANIES AFFORDING COVERAGE
COMPANY ACE American Insurance Company i
PHONE- (817) 810-4000 FAX- (817) 339-2019 A
INSURED COMPANY National Union Fire Ins Co of Pittsburgh
Instar services Group, Inc. B
Instar services Group, L.P. COMPANY a
dba Action Fire Instar services Group c
30 Haynes circle C c
Chicopee MA 01020 USA COMPANY
D
COVE a � M
RAGES., KR3? E?p�Y,
5
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.
T TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LT DATE(MNI/DD/YY) DATE(MM/DD/YY)
n oc
• GENERAL LIABILITY HDOG2169958S 08/06/04 10/01/05 GENERAL AGGREGATE $2,000,,000 oc
General Liability — d
X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMPIOP AGG $2,000,000 rr
CLAIMS MADE �OCCUR PERSONAL&ADV INJURY $1,000,000 C
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $1,000,000 n
v
FIRE DAMAGE(Any one fire) $100,000
MED EXP(Any one person) $S,000 Z
a
• AUTOMOBILE LIABILITY ISAH08009892 08/06/04 10/01/OS COMBINED SINGLE LIMIT S1,000,000
X ANY AUTO Business Auto
L
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT
AGGREGAT
B EXCESS LIABILITY BE1647753 08/06/04 10/01/05 EACH OCCURRENCE $5,000,00
X UMBRELLA FORM Umbrella Liability AGGREGATE $5,000,00
OTHER THAN UMBRELLA FORM Retained Limit Amoun $10,00
A WORKER'S COMPENSATION AND WLRC43969201 08/06/04 10/01/05 X TORY LIMITS OTH
EMPLOYERS'LIABILITY workers' Compensation EL EACH ACCIDENT $1,000,000
THE PROPRIETOR/ X INCL EL DISEASE-POLICY LIMIT $1,000,000
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $1,000,000_
t�
"L-
DESCRIPTION OUntPERAIIOPRf 85ATIONSNEHICLES/SPECIAL ITEM:
#S 14511 yr
R
�J
CERTIFICATE HOLDER 66,
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE
i.�
The commonwealth EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVORTO MAIL t'
of Massachusetts 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Department of Industrial Accidents
office of Investigations BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
600 Washington Street OF ANY KIND UPON THE COMPANY. ITS AGENTS OR REPRESENTATIVES.
Boston MA 02111 USA AUTHORIZED REPRESENTATIVE `Y
rte' .� .Se7raeca a�I �exaa. 9.ec.
`r' c, 4: ,� . "I., `°*..:y
ACORD nz ..mss. .:�t�r ..4..;,. s•...ttmE::;
25-5 1/95 .,, �. � ..ra .
. j
_ - ✓�ie �omz�ieanurealC� a�i�lauczc�ivaell �°
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 112812
Expiration: 4/27/2005
Type: DBA
ACTION FIRE RESTORATION
30 HAYNES CIR
CHICOPEE,MA 01020
Administrator
�lre VOmvnxc»uue¢cu� a�✓�aoaar.�ivaeka �;
BOARD OF BUILDING REGULATIONS
i License: CONSTRUCTION SUPERVISOR
1J Number:CS 069770
Birthdate 1210411956
Ex Tres ti 4%2066 Tr.no: 5771.0 4
Pr , 4 I
Restricted 00 `
JAMES D HALL
17 MYRTLE AVE
HOLYOKE, MA 01040
Commissioner 1
t
Versionl.7 Commercial Building Permit May 15,2000
SEC
TION:10=STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......
SECTION 11-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT,OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize _bAS11AC !;0t A(_S Cjlj� to act on
my behalf, in all matters relative to work authorized by this building permit a plication.
Signature of Owner Date
I, as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
SECTION 1Z-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : \\ �fL,S A U
License Number
30 a�e S CkCt k C,V\� r� L Wk�
Address Expiration Date
-7 560
Sign ture 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....... P/ No...... ❑
Versionl.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
92 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
I
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
Amo&( Say,�a rcpx Not Applicable ❑
Company Name:
�1pi ft E-5 a— (cch'ijslay "T as Mu(f
Responsible In Charge of Construction
30 -\-\I r`rAA 9L- 'll ()10(1 ?
Address
S knature Telephone
Version 1.7 Commercial Building Permit May 15,2000
7. Water S} ply(M.G.L. c. 40, §54) 7.1 Flood Zone Information: 7.3 Sewage DKposal System:
Public C9' Private ❑ Zone: Outside Flood Zone ❑ Municipal VOn site disposal system ❑
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location
A. Has a Special Permit/Variance/Finding/ever been issued for/on the site?
NO DON'T KNOW Y YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page arid/or Document#
B. Does the site contain a brook, body of water or wetlands? NO V 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 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES _
No
IF YES, describe size, type and location:
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FO'R PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs [ ]
SECTION 5 - USE GROUP AND CONSTRUCTION'-TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly 10 A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational O 2B ❑,
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1.3 ❑ 3B ❑
M Mercantile ❑ i 4 ❑
— i
R Residential IV R-1 ❑ R-2 ❑ R-3 ❑ ! 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility lili Specify:
1911 OLZ'i RSL
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: Ta%Qul MAl_ Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
OFFICE USE`.flNLY
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
L y
Floor Area per Floor(sf) 1st
f �
� �s 4 a
nd
1st 2 a�' X
,^A
2nd 3rd
1
4th
3'd r
W .,
4th
Total Area (sf) Total Proposed New Construction (sf) 77
....................... ...........
Total Height(ft)
y
Total Height ft ------
Versionl.7 Commercial Building Permit May 15,2000
pity of Northampton # ' :
Building D6,partment b 1
212 Main Streete erg ept el �I
Room 100 # Vrfv i a
Northampton, MA010605�s�� I
phone 413.587-1240 Fax 413-587.1272 0100"" ite
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
This section to be completed by office ,
1.1 Property Address:
Map 3 ,
Lot l�lrsy#
L' a Zone.- Overlay.District
T
Elm St: Ditrict CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
game ) �— Current Mailing Address:
� Telephone
2 2 Authorized Agent:
Name(Print) Current Mailing A dress:
Signature Telephone
SECTION 3 . ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit 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
00 Check Number
6. Total =(1 + 2 + 3 + 4 + 5)
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2005-1008
APPLICANT/CONTACT PERSON ACTION FIRE-INSTAR SERVICES GROUP LP
ADDRESS/PHONE 30 HAYNES CIRC CHICOPEE (413)594-7800
PROPERTY LOCATION 28 WESTWOOD TERR
MAP 35 PARCEL 136 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out —00 42 an
Fee Paid
T_ypeof Construction: REPAIR FIRE DAMAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 069770
3 sets of Plans/Plot Plan
THE FOL OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Additional permits required(see below) /qO vs'� -Otis 164— eAZWaNr
PLANNING BOARD PERMIT REQUIRED UNDER:§
U O To eoDC
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan .4eS7,R
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 Co Sion
Signature o 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.
28 WESTWOOD TERR BP-2005-1008
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 - 136 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:FIRE BUILDING PERMIT
Permit# BP-2005-1008
Project# IS-2005-1227
Est. Cost: $50000.00
Fee: $250.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ACTION FIRE-INSTAR SERVICES GROUP LP 069770
Lot Size(sa. ft.): 10105.92 Owner: MORRISSEY EDWARD
Zoning: SR Applicant. ACTION FIRE-INSTAR SERVICES GROUP LP
AT. 28 WESTWOOD TERR
Applicant Address: Phone: Insurance:
30 HAYNES CIRC (413) 594-7800 Workers
Compensation
CHICOPEEMA01020 ISSUED ON:4127105 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR FIRE DAMAGE
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 Sienature:
FeeType: Date Paid: Amount:
Building 4/27/05 0:00:00 $250.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
28 WESTWOOD TERR BP-2005-1008
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35- 136 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: FIRE BUILDING PERMIT
Permit# BP-2005-1008
Proiect# IS-2005-1227
Est. Cost: $50000.00
Fee: $250.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Grow: ACTION FIRE-INSTAR SERVICES GROUP LP 069770
Lot Size(sa. ft.)10105.ti_2 Owner: yf0RR_iSSE fD,;A D
Zoning: sR Applicant: ACTION FIRE-INSTAR SERVICES GROUP LP
AT. 28 WESTWOOD TERR
Applicant Address: Phone: Insurance:
30 HAYNES CIRC (413)594-7800 Workers
Compensation
CHICOPEEMA01020 ISSUED ON:4127105 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR FIRE DAMAGE
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:
J
Final:"'-l—'7"` a tt'� "Final: Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: 5 .,i P , / j Oil: Insulation:
Final: x ? `t-` ;y . Smoke Final: Off- 7_f�J-
x!
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGUL IONS.
�W
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 4/27/05 0:00:00 $250.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo