38B-006 (66) :APO— ,
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TRAVELERS J WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
r
TYPE V INFORMATION PAGE WC 00 00 01 ( A)
I
POLICY NUMBER: (DTACRUS-299KG20-3-09)
NEW-09
INSURER: TRAVELERS CASUALTY AND SURETY COMPANY
NCCI CO CODE: 11223
1.
INSURED: PRODUCER:
A.R . GREEN & SON, INC. T P DALEY INS AGCY INC
19 ST. JAMES AVENUE PO BOX 1150
HOLYOKE MA 01040 WEST SPRINGFIELD MA 01090
Insured is A CORPORATION
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 01 -01 -09 to 01 -01 -10 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
CT MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 500000 Each Accident
Bodily Injury by Disease: 500000 Policy Limit
a
Bodily Injury by Disease: $ 500000 Each Employee
m C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
AL AR AZ CA CO DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO
MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI WV
m
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
0
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
W— Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 01 -13-09 SM
OFFICE: HARTFORD 084
PRODUCER: T P DALEY INS AGCY INC G7940
012697
- The Commonwealth of Massachusetts
Department of Industrial Accidents
Office oflnuestigations
t 600 Washington Street, 7'h Floor
Boston,Mass. 02111
Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
Applicant information.: Please PRINT lezibly
name: -4
n
address::\ VA zS s o.�M�3 .+,V.",
city N-�Vml � c state: P-NYA zip: 6161] phone#
work site location full address): Jv'^� � � C ��� "3 l?�I 3—{
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction XRemodel
❑ I am a sole proprietor and have no one working in any capacity. ❑ Building Addition
( I am an employer providing workers' compensation for my employees working on this job.
company name:t'i �"n.���► - N �V
address: C\ 5zi—,
city• ��Jl tJ�CS�.—, �� 01 phone#: '113- "53V7NLI, -7
insurance co 10%A ELE-R 3 policy# U i Rg;rALks"aRl K GZ0 " 3—49
❑ I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
companv name:
address:
city: phone#:
insurance co policy#
company name:
address:
city: phone#:
insurance co _ policy#
Attach additional sheet if necessary
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500,00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certi y under thepains andpenalties ofperjury that the information provided above is true and correct.
Signature
Q � Date
4 k3
;� It
Print name i'1 ur S 3�-1 Z A -a''L I%`ice
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
[]Health Department
contact person: phone#; ❑Other
(revised Sept.2003)
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 0 No 0
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
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 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: ay S. G S. 38e/3
License Number
sT s � / ! s
Sczwv►c vix or,.,P�K� /7/l 07 4L O
Address Expiration Date
/3-530 -79
Sifi<ature 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 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:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
(Q J-C, r—I e i C CJ
Name LIN & SHARPLES Area of Responsibility
DG
Address 435 Cottage Street -7
Registration Number
pringf field, MA `fr 3� 7 32-y3 3(, ��e 3p 20 f O
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
A 1_! . G-iAC; L St" Not Applicable ❑
Company Name: I
Q)6 v�- QYa1 ',-.4NP,,,
Responsible In Charge of Construction i
Address
a 53$-:1Ty-7
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONI&Z7 t
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 Parkin;Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO @ DON'T KNOW O 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 Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 Date Issued:
C. Do any signs exist on the property? YES 0 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:
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 0 NO T
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❑ Change of Use❑ Other❑
Brief Description Enter a brief description here.
Of Proposed Work: Remove a wall and relocate a door frame
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)
1S 1S
2nd 2nd
3 rd 3rd
4tn
4 m
Total Area (sf) Total Proposed New Construction (so
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 E] Zone Outside Flood Zone❑ Municipal ❑ On site disposal system[:]
Version 1.7 Commercial Building Permit May 15,2000
Department use only
City of Northampton StatusofPermit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
rvn •L Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 41$-5871240 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
Facilities Management Map Lot Unit
126 West Street
Northampton, MA Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
SmitF College Facilities Management
Gary Har ell, Project Manager 126 West Street
Name(Print) Current Mailing Address: Northampton, MA
Signature Telephone 413-585-2441
2.2 Authorized Agent:
Lindgren & Sharples 435 Cottage Street
Name(Print) Consulting Engineers Current Mailing Address: Springfield, MA
Signature Telephone 413-732-4336
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building $3,000 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) $55.00
5. Fire Protection
6. Total = (1 +2 +3+4+5) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2009-1009
APPLICANT/CONTACT PERSON A R GREEN&SON INC
ADDRESS/PHONE 19 ST JAMES AVE HOLYOKE (413)538-7947
PROPERTY LOCATION 126 WEST ST
MAP 38B PARCEL 006 001 ZONE SI(100)//WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: REMOVE WALL&RELOCATE DOOR FRAME
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 038817
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION P$LrSENTED:
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
Signature of BuAdini 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.
=° BP-2009-1009
GIs#: COMMONWEALTH OF MASSACHUSETTS
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-2009-1009
Project# JS-2009-001452
Est. Cost: $3000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: A R GREEN & SON INC 038817
Lot Size(sq. ft.): 9365.40 Owner: SMITH COLLEGE OFFICE OF TREASURER
Zoning: SI(100)//WP Applicant: A R GREEN & SON INC
AT: 126 WEST ST
Applicant Address: Phone: Insurance:
19 ST JAMES AVE (413) 538-7947 Workers
Compensation
HOLYOKEMA01040 ISSUED ON.61212009 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE WALL & RELOCATE DOOR FRAME
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 6/2/2009 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo