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32A-175 (2) ��•-..1 CATASPR-01 LLANDRY A�O�RO` CERTIFICATE OF LIABILITY INSURANCE [__DATE(MMfDONYYY)v5/2o1s 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 Linda Landry _ _ HUB International NE LLC formerly FieldEddy PHONE `-413 733-3131 — _._ - FAx 79 Lyman Street -(A/C No E�<�--? 1�AfC NoZ_(413)733-3194 E-MAIL South Hadley,MA 01075 ADDRESS:llandry@a fieldeddy_com - INSURER(S)AFFORDING COVERAGE NAIC ft INSURER A:Citizens Insurance Co Of America 31534 - — __. - -- - -------- - ------ ... -- _..__._._._.._—.._.._._...-- ...... --- ------- INSURED INSURER B:Allmerica Financial Benefit 41840 Catamount Spring LLC dba Cellu Spray INSURER C:Hanover Insurance Company - -- - - 22292 - --------------- --- 55 Maple St. INSURER 0 Northampton,MA 01062 _I_NSURER 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. INSR TYPE OF INSURANCE Ab i POLICY NUMBER POLICY DOlYYYY MMlOCWYYYY LIMITS LTR A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 DAMAGE'T'0_Rl=NT8U,_...___....----------- _�CLAIMS-MADE �]OCCUR BN9114191 06!47!2015 06!17/2015 pREMIsES.Ea occurrence $ 1,000,00 _ __(_—----_Z-- ME EXP(Any one person) $_ 10,000 — PERSONAL_&ADVINJURY _$ - 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE _ $ 2,000,00 POLICY r ll PRO X LOG PRODUCTS-COMPlOP AGG $ 2,000,00 L..-.IJECT OTHER: ---�.—._---$-.....------- AUT33OM064 COMBINED SINGLE LIMIT ELIABILITY $--._.......-.. 1,000,00 B I ANY AUTO AWN9132852 1 06/1712015 0611712016 BODILY INJURY(Per person) $ ALL OWNED �( SCHEDULED { I --------- __._.. _._ BODILY INJURY(Per accident) $ AUTOS _-. AUTOS -- NON-OWNED I PROPERTY DAMAGE-__-. - ____.. ........... X HIREDAUTOS X AUTOS I _jPeraccident}___________ $ $ UMBRELLA LIAB I OGCUR I EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ OED RETENTION$ $ WORKERS COMPENSATION X STATUTE _X OTRH- AND EMPLOYERS'LIABILITY - C ANY PROPRIETORMARTNEWEXECUTIVE YF N f A WHN9115267 06/14/2015 06/14/2016 E.L.EACH ACCIDENT $ 1,000,00 OFFICER(MEMBER EXCLUDE[ (Mandatory In NH) EL DISEASE-EA EMPLOYE $ 1,000,00 if yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS t LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Kris Thomson Carpentry THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P try ACCORDANCE WITH THE POLICY PROVISIONS. 362 kennedy Rd. Lee ds,MA 01053 HUB International New En land LAC Lee AUTHORIZED REPRESENTA �„rorMyy ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD C e ) I u -Sp P- lnsv ���- � • C,-ik� V-\ avr 5 "nom Aare t The Commonwealth of Massachusetts Departratent oflit dustrial Accidents .r Office of Investigations 600 TVashington Street Boston, MA 02111 www.niass.a ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Y!!t 1 /�1' 5 1 A6164 S0 P-1 _ Address: 3 L2_ K-e %A r.e ak City/State/Zip')—e U!,-, it -r, lb Ja S-3 Phone#: '`�l S 9. Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. K I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working or me in an capacity. employees and have workers' g y p �'� 9. F1 Building addition [No workers' comp.insurance comp. insurance.$ d.ire re q u 5. f_1 We are a corporation and its 10.❑ Electrical repairs or additions ] 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.7 Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.® Other r 4 c_ employees. [No workers' 1 � 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 anew 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 thepolicy and job site information. Insurance Company Name: @ (gyp pf Policy#or Self-ins.Lic.#: (gS U U 1� C-T D (!> O I 7 /� Expiration Date: 30 Job Site Address:"11D// ?> tr3 A ti e. �' . Ci /State/Zi ty p:1s1_%C �,Ml C)_I()6 b 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 to s a d penalties of perjruy that the information provided above is true and correct. signature: Date: Phone#: ' �c! S' 64:1 / Official use only. Do not write in this area,to be completed by cit)x 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#: iI 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 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT LJ_ 4r t I, _ e _ ir-C-4 )_ , brl d POwner of the subject property hereby authorize 7ti rl S �J�V1. ao act on my beh f, ' all matters rela 've to rk auth ized by this building permit application Signature of Owner Date I, ! 5 .. �.... 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 pen (ties of perjury i_ _ Fyn 561 Print Name Signature of Owner/Agen Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ ..._... ....... ....... Name of License Holder:. License Number lzd Address Expiration Date Sig ure 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 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 9.2 Registered Professional Engineer(s): Name Area of Responsibility __. Address Registration Number Signature 9 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 I Expiration Date 9.3 General Contractor "_� L .►!t h. r!1j��G.►, 1, r' Not Applicable ❑ Company Name: Responsible In Charge of Construction r is ow Address Signature Telephone i I I Versionl.7 Commercial Building Permit May 15,2000 S. NORTHAMPTON ZONIRZ—] Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: . .... R:1 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 DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW Q 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 0 YES 0 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 0 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 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,ex avation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. _ y Version l.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:< P. base IM Q h nsv � . �' ...: �' WC. O S _ .s roc , .'aQ ti ,.-±�.S�uu..fi��c,k, 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 ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ I-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) 1St _ _. 1St 2nd 2nd 3 d 3,d 4ih 4m .......... _ .............. 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[-] i I ' I Versionl.7 Commercial Building Permit May 15,2000 Department use only ity of Northampton Status of Permit: uilding Department Curb Cut/Driveway Permit - JAN - 5 'OI6 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability LN11 N r thampton, MA 01060 Two Sets of Structural Plans r -587-1240 Fax 413-587-1272 �Plot/Site Plans ` Other Specify L��ATION 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 Map Lot Unit /_ Zone Overlay District NUS f-ka-v _ zJ� Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT / 2.1 Owner of Record: _. - 'S.{ t l\( Name g Address: f Print ( ) ) 1� Current Mailiru � Signature Telephone \ ` 2.2 Authorized Agent: .((�° S zS S o ►-� "� to Z lGe Name Print Current Mailing Address: ol C�`r o Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building J `: (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=0 +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-2016-0867 APPLICANT/CONTACT PERSON NORTHAMPTON HISTORICAL SOCIETY DAMON HOUSE ADDRESS/PHONE 46 BRIDGE ST NORTHAMPTON01060 PROPERTY LOCATION 46 BRIDGE ST MAP 32A PARCEL 175 001 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 Fee Paid Typeof Construction: INSULATE BASEMENT WALLS& SHEETROCK New Construction Non Structural interior renovations Addition to Existin14 Accessory Structure Building Plans Included: Owner/Statement or License 084152 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOJR XATION 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 Delay Sig ure o Building Mfficial 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. 46 BRIDGE ST BP-2016-0867 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A- 175 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT g or v Permit# BP-2016-0867 Project# JS-2016-001462 Est. Cost: $4000.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KRIS THOMSON 084152 Lot Size(sg. ft.): 23261.04 Owner: NORTHAMPTON HISTORICAL SOCIETY DAMON HOUSE Zoning_CB(100)/ Applicant: KRIS THOMSON AT: 46 BRIDGE ST Applicant Address: Phone: Insurance: 362 KENNEDY RD (413) 549-1027 O LEEDSMA01053 ISSUED ON:11612016 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSULATE BASEMENT WALLS & SHEETROCK 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 1/6/2016 0:00:00 $100.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner