31A-043 (3) 273 CRESCENT ST BP-2020-0535
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV.Block: 31A-043 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPAIR DECK FLOORING L UlLD tN G PERMIT
Permit# BP-2020-0535
Project# JS-2020-000923
Est.Cost: $4000.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ERICA GEES CS111018
Lot Size(sg. ft.): 7274.52 Owner: STIEBEL PROPERTIES INC C/O STIEBEL PROPERTIES INC
Zoning: URB(,100)/ Applicant: ERICA GEES
AT: 273 CRESCENT ST
Applicant Address: Phone: Insurance:
PO BOX 1210 (413) 222-7776 Workers Compensation
GREENFIELDMA01302 ISSUED ON.1012912019 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE DECK BOARDS AND RAIL
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:
FeeTvpe: Date Paid: Amount:
Building 10/29/2019 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Versionl.7 Commercial Building Permit May 15,2000
RECEIVEDDepartment use only
Cit of Northampton Status of Permit:
Bu ding Department Curb Cut/Driveway Permit -
OCT 2 5 2019 12 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
14or&ton, MA 01060 Two Sets of Structural Plans
WEPT.OF su "O
NORTHAMPTON. AS#0443-5 7-1240 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
8 1-9�
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
s :
2-3 CfeSCeri-l- Sf - Map Lot Oma)- Unit i
✓f 1//glJ����� /' � � Zone (x(12 Vj Overlay District
= A Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Sfil e-5 6 L- 1 .3 P E-2-T,ffS Z4Z SLA01 II CCf-h�ly�
Name(Print Current Mailing Address: U/cam
X4[3 10 . 47 l x,
Signature Telephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building � �jJIvU _ (a)Building Permit Fee
2. Electrical �axn.�,a _- (b)Estimated Total Cost of
Construction from 6 -
3. Plumbing = Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection �M `
6. Total=(1 +2+3+4+5) -7 lCheck Number 6te
This Section For Official Use Only
Building Permit Number Date
Issued
SigMture:
LI
Bui ing Commissioner Inspector of Ojildings Date
ou X e) I ma)) , 60 vl'k ( 4t 3.. zZZ. 77 7(,
1
Versionl.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: _ Rn.r33 ._ 1
Rear J _S
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved 17:j
azkin
#of Parking Spaces -'
Fill: __ ------- ------
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW 0 YES
IF YES: enter Book Page and/or Document#; J'
B. Does the site contain a brook, body of water or wetlands? NO a DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
i
C. Do any signs exist on the property? YES 0 NO 19
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,grading,excavation,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.
Versionl.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. epiGCc aea- J' ✓o2S �- ��
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 15 R-1 ❑ R-2 R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B Er
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): _ i 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)
st
1st L ._
2nd 2nd m..._._„ ---s
rd 3 rd
4t'
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
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 4 No To
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, % .. `� .�r' '� J _J-_L_�t���� �. V�E' 1,as Owner of the subject property
hereby authorize.
act on my be al a Ct rs relative to work authorized by this building permit applicatio
n._
_ .1
vel
/0 Z,r• l q
Signature of O Date
I,t)u K C,�� 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 thepains and penalties of pedury
Print nX —
yc 7�ILIL GI
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: (C Q U G7teS
License Number
�
��
-1 -
Addre Expiration Date
Z.ZZ 7�
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 W 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 _ I
y Expiration Date
Signature Telephone -
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
i
Signature Telephone Expiration Date
Name Area of Responsibility
Address _ RegistrationNumber
Signature Telephone Expiration Date
Name Area of Responsibility
�1
Address Registration Number
1
Signature Telephone Expiration Date
9.3 General Contractor
_� -- Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Ad
CZ- 6 7'l
Signature Telephone
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: 2-73 C(tSC-P-v1+' St- -
The debris will be transported by: to S Pr G h�
The debris will be received by: (ASN U��
Building permit number:
Name of Permit Applicant S+jtl P(U jpe+-- --5
25 DO- 2219
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information f (� Please Print Legibly
C
Name (Business/Organization/Individual): `,T"j 'c ht( N ope([L f C,5
Address: Z1+2- SOf(�A K< S t'
City/State/Zip: Kb1a KP,_ M4 C1740 Phone#: -' I3, ZZZ- 7 7 7 .--
Are you an employer?Check the appropriate box: Type of project(required):
l.®I am a employer with_L' mployees(full and/or part-time).' 7. []New construction
2.[:]1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.[J I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 E] Building addition
4.[—]1 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
14.®.Other I)e&— Re A�, �S
6.[:]We are a corporation and its officers have exercised their right of exemption per MGL c.
h
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
IL
'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.
tContractors 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. I
Insurance Company Name: VI/t� (�,i( f�7►�I /l ll1 ell
Policy#or Self-ins.Lic.#: �M ZBUORy�`7 )&(P2_o(9 A- Expiration Date: 2- ?�
Job Site Address: -73 C'(f S Ce✓►{" City/State/Zip: Cft,44(z� D 1(760
Attach a copy of the workers'compensation policy declaration page(showing the policy number and ze and date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ido hereby certify un��rtit pains andpenalties ofperjury that the information provided above is true and correct
Si afore: / Date:
Phone#:
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#:
AC"RL> CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DD/YYYY)
10/25/2019
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 have ADDITIONAL INSURED provisions or 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:CONTACT Mary Odabashian
Webber&Grinnell PHONE (413)586-0111 FAX (413)586-6481
A/C No Ext: A/C,No
8 North King Street E-MAIL modabashian@webberandgrinnell.com
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
Northampton MA 01060 INSURER A: AIM 33758
INSURED INSURER B:
Stiebel Properties,Inc.,DBA:Frank Stiebel INSURER C:
242 Suffolk Street
INSURER D
INSURER E:
Holyoke MA 01040-4456 INSURER F:
COVERAGES CERTIFICATE NUMBER: EXP 10/2020 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 POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
A A N I ED
CLAIMS-MADE OCCUR PREMISES Ea occurrence $
MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER
PRO- GENERAL AGGREGATE $
POLICY JECT LOC
PRODUCTS-COMP/OPAGG $
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY Per accident
AUTOS ONLY AUTOS ( ) $
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY Per accident $
$
UMBRELLALIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB---,—,—HCLAIMS-MADE AGGREGATE $
DED RETENTION $ $
WORKERS COMPENSATION PEROTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
A ANY PROPRIETOR/PARTNER/EXECUTIVEN/A WMZ80080071662019A 10/02/2019 10/02/2020 E.L.EACH ACCIDENT $ 500,000
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS/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
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
@ 1988-2015 ACORD CORPORATION. All rights reserved.
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