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22B-040 (6) Rey S.Brown Architects 85 Chilson Road—Wilbraham, Massachusetts 01095 ph 413,596.2360—fax 413.596.2360 email rsba85@yahoo-com CONSTRUCTION CONTROL AFFIDAVIT PROJECT NUMBER: 14-F-MA-1 DATE: 9123/2014 PROJECT TITLE: Roof Replacement PROJECT LOCATION- 221 Pine Street, Florence, MAO 1060 NAME OF BUILDING: Brush Works SCOPE OF PROJECT: Nloisture Scan, Replace wet insulation, Add insulation,New Single Ply IN ACCORDANCE WITH THE 8th Edition MASSACHUSETTS STATE BUILDING CODE, 780 CMR, CHAPTER 1, SECTION 107.6.1, 1 Roy S. Brown MASSACHUSETTS REGISTRATION NO. 4293 BEING A REGISTERED PROFESSIONAL ARCHITECT Xt QUPHI X r 10 1-1 r-1=LIT ITI HEREBY CERTIFY THAT V 1-0"U/ I I I L, CONCERNING EX] ARCH ITEC-I"URAL ❑ STRUCTURAL E] MECHANICAL ELECTRICAL FIRE: PROTECTION 0 OTHER FOR THE ABOVE NAMED PROJECT F 1V1 I 1�1 S4-41-w __A41p,�40A OT I A 111C cno-.T� X4 Ig DD A C A\Tn A I FURTHER CEWI'IFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR BASIS TO DETERMINE THAT TI-IE WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR Tf IE BUILDING PERMIT AND St[ALL BE RESPONSIBLE FOR THE FOLLOWING: I. Review of shop drawings,samples and other submittals of the contractor as required by the construction contract documants as submitted for building permit,and approval for conformance to the design concept. 2. Review and approval of the quality control procedures for all code required controlled materials. 3 t Special architectural or engineering professional inspection of critical construction components requiri 11, controlled materials or construction specified in the accepted engineering practice standards listed in Appendix B. I SHALL SUBMIT PERIODICALLY, A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE BUILDING INSPECTOR. UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AND AN AFFIDAVIT OF COMPLETION AS TO THE SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUPANCY. T Q'M 4- Mgmatur�) -7, Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet (991m)of enclosed space. i Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPS Massachusetts - Department of Public Safety Boaird of Building Regulations and Standards construction Super%kor License: CS-099798 { DANIEL P CARNEY 34 HORSESHOE CIRCLE" WARE MA 01082 nt Expiration Collin Its sloe t.( 08/19/2015 {4 P DPCARN1 OP ID:AD CERTIFICATE OF LIABILITY INSURANCE 1 DA 09/11/201 14 4 D/ 09/11/ 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 NAME:CT Angela DiAugustino PHILLIPS INSURANCE AGENCY INC ONE 413-594-5984 FAX 4 97 CENTER STREET (PANIC,No Eat: A/C No): 13-592-8499 CHICOPEE,MA 01013 E-MAIL PHILLIPS INSURANCE AGENCY INC ADDRESS:Angela@phillipsinsurance.com _ INSURER(S)AFFORDING COVERAGE _ NAIC# INSURE RA:Admiral Insurance Company INSURED D.P.Carney Construction,Inc. INSURER B:Selective Insurance 12572 Mr.Dan Carney 34 Horseshoe Circle INSURER C:Chartis Company Ware, MA 01082 INSURER D:Admiral Insurance Company 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. ILTR TYPE OF INSURANCE POLICY NUMBER MM DDY EFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 • X COMMERCIAL GENERAL LIABILITY X CA000018049-01 08/0112014 08/01/2015 A � N 50 OO PREMISES Ea occurrence $ CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,00 • X XCU 08101/2014 08/01/2015 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY[-X—] PRO LOC $ AUTOMOBILE LIABILITY CEa accident OMBINED SINGLE LIMIT $ 1,000,00 B ANY AUTO A9094953 08/01/2014 0810112015 BODILY INJURY(Per person) $ ALL OWNED X SC AUTOS HEDULED AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS PER ACCIDENT UMBRELLA LIAB i X OCCUR EACH OCCURRENCE $ 5,000,00 D X EXCESS LIAB CLAIMS-MADE F-X000013605-01 08101/2014 08/01/2015 AGGREGATE $ 5,000,00 DIED I X I RETENTION$ 10,000 $ WORKERS COMPENSATION X WC STATU- 70TH- AND EMPLOYERS'LIABILITY TORY LIMITS ER C ANY PROPRIETOR/PARTNER/EXECUTIVEY/N WC009930624 11/15/2013 11/15/2014 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? N/A -- (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 I:E DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: Re-Roof AB Roof Brushworks (23400 sq) located at 221 Pine St Florence, MA Mount Holyoke Property Management LLC is listed as Additional Insured on the General Liability policy due to CERTIFICATE HOLDER CANCELLATION MOUNTHL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Mount Holyoke Property ACCORDANCE WITH THE POLICY PROVISIONS. Management LLC Ad Berizin AUTHORIZED REPRESENTATIVE 667 Main St Holyoke, Holyoke, MA 01040 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations d I Congress Street, Suite 100 Boston,MA 02114-2017 M www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): D.P. Carney Construction, Inc. Address:34 Horseshoe Circle City/State/Zip:Ware, MA 01082 Phone#:413-967-7124 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 15 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working or me in an 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.❑ 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.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no roof replacement employees. [No workers' 13.❑E Other p comp. insurance required.] 'Any applicant that checks box#I 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:Chartis Company Policy#or Self-ins. Lic. #:WC009930624 Expiration Date:11-15-2014 Job Site Address: 221 Pine Street City/State/Zip:Florence, MA 01062 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 certi under the pains and penalties of perjury that the information provided above is true and correct. Si nature: Date:September 11, 2014 Phone#: 413!9d7124 tr- -) 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#: Version 1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes Q No Q SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I Brushworks, LLC as Owner of the subject property hereby authorize D.P. Carney Construction, Inc. to act on my behalf,in all matters relative to work authorized by this building permit application. 09/11/2014 6 Si ure of O ner _ Date Brushworks, LLC 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. Brushworks, LLC Print Name 09/16/2014 Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Daniel P. Carney 099798 License Number 34 Horseshoe Circle, Ware, MA 01082 08/19/2015 Address Expiration Date (413) 967-7124 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 0 No 0 Version 1.7 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: , 1 ra am, 0a (jQoLJd1 Not Applicable ❑ Name(Registrant): ) 85 Chilson Road, Wilbraham, MA 01095 Registration Number Address `�&u b7m,it (413) 596-2360 Expiration Date Sig ure Telephone 9.2 Registered Professional Engineer(s): Roy Brown Architects Name Area of Responsibility 85 Chilson Road, Wilbraham,MA 01095 Address Registration Number 'R%,, (413) 596-2360 Sign to 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 D.P. Carney Construction, Inc. Not Applicable ❑ Company Name: Daniel P. Carney Responsible In Charge of Construction 34 Horseshoe Circle,Ware, MA 01082 ddress (413) 967-7124 Sig ure Telephone Version 1.7 Commercial Building Permit May 15,2000 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 Q DONT KNOW Q YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW e YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW Q 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 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 O NO Q 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 O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version 1.7 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❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing Q Change of Use❑ Other❑ Brief Description Re-roof AB roof Brushworks (23400sf) 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 ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ 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 ❑ 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 BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1 St 1 St 2nd 2nd 3rd 3rd 4th 4th 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❑ Version 1.7 Commercial Building Permit May 15,2000 Department use only City of Northampton Status of Permit: Building Department Curb CuttDrivewayPermit 2��4 212 Main Street SewertSepticAvailability 1! ` -' - Room 100 WaterNVell Availability Plumbing&Cias Ins i rthampton, MA 01060 Two Sets of Structural Plans ottham M 1-587-1240 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 221 Pine Street Map Lot Unit Florence, MA 01062 Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Brushworks LLC 221 Pine Street, Florence, MA 01062 Name(Print) Current Mailing Address: r� (413) 534-0955 Signature'�� S a C,)'' Telephone 2.2 Authorized Agent: D.P. Carney Construction, Inc. 34 Horseshoe Circle, Ware, MA 01082 Name(Print) Current Mailing Address: (413) 967-7124 Signature Telephone SECTION 3- IMATED CONSTR N CQSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building $107,776.00 (a)Building Permit Fee 2. Electrical $0.00 (b)Estimated Total Cost of Construction from 6 3. Plumbing $0.00 Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection $0.00 6. Total=0 +2+3+4+5) r •00 Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0323 APPLICANT/CONTACT PERSON D P CARNEY INC ADDRESS/PHONE 34 HORSE SHOE CIRCLE WARE (413)543-4803 PROPERTY LOCATION 221 PINE ST MAP 22B PARCEL 040 001 ZONE SI(115)/WP(115)/WSP(1)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: REROOF AB ROOF(23,400SF) New Construction Non Structural interior renovations Addition to Existin Accessory Structure Building Plans Included: Owner/Statement or License 99798 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO .ATION PRESENTED: pproved 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 m ' io ela Signature of 13 ilding O cial 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. 221 PINE ST BP-2015-0323 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 22B-040 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:ROOF BUILDING PERMIT Permit# BP-2015-0323 Proiect# JS-2015-000602 Est. Cost: $107776.00 Fee: $646.66 PERMISSION IS HEREBY GRANTED TO Const. Class: Contractor: License: Use Group: D P CARNEY INC 99798 Lot Size(sq. ft.): 145926.00 Owner: BRUSH WORKS THE LLC Zoning: SI(I 15)/WP(115)/WSP(1)/ Applicant: D P CARNEY INC AT. 221 PINE ST Applicant Address: Phone: Insurance: 34 HORSE SHOE CIRCLE (413) 967-7124 WC WAREMA01082 ISSUED ON.912412014 0:00:00 TO PERFORM THE FOLLOWING WORK:REROOF AB ROOF (23,400SF) 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 9/24/2014 0:00:00 $646.66 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner