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37-060 (14) BP-2021-2005 272 GROVE ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 37-060-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2021-2005 PERMISSION IS HEREBY GRANTED TO: Project# CARPORT Contractor: License: Est. Cost: 13600 WEST SIDE CONTRACTORS INC 104211 Const.Class: Exp.Date:04/26/2022 Use Group: Owner: TRI COUNTY YOUTH PROGRAMS INC Lot Size (sq.ft.) Zoning: URB Applicant: WEST SIDE CONTRACTORS INC Applicant Address Phone: Insurance: 7 RISING CORNER RD 413-650-5959 VWC10060245922021 SOUTHWICK, MA 01077 ISSUED ON:10/07/2021 TO PERFORM THE FOLLOWING WORK: REPAIR CARPORT 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. Signature: tot • ' • y9 , ''a • Fees Paid: $100.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner l RF v Et Oct 6 he ommonwealth of Massachusetts 4/049/ Office of Public Safety and Inspections NOti,8 /non Massachusetts State Building Code(780 CMR) �,:,; 'TiA4 t Ap 'cation for any Building other than a One-or Two-Family Dwelling 't f)1O ONS (This Section For Official Use Only) Building Permit Number6f A)" ate Applied: Building Official: SECTION 1:LOCATION No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below Existing Building 0 Repair Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No 0 Is an Independent Structural Engineering r Review required? / Yes 0 No 0 Brief Descri lion of Propojfd Work: PAD e R.X l {-� �g9 r'.e 0/7 �e SieYC D P q1�,� ' / Re.fie / l SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 0 I-2❑ I-3❑ I-4❑ M: Mercantile❑ R Residential R-10 R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ HA 0 IIB ❑ MA IIIB ❑ IV 0 VA VB 0 SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal: A trench will not be Licensed Disposal Site 0 Public 0 Check if outside Flood Zone❑ Indicate municipal 0 required 0 or trench or specify: Private 0 or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes 0 or No 0 Yes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION nd Address of Property Own ed ,, 1 N j2 Qo-r� ,t1-& 1" Jo a7-2 472O /�J ,h'4,1,�7lYL Name(Print) No.and Street City/Town Zip Pr`perty Owner Contact Information: /� ,--1 10 !'-2 ' s'S = _ yd'Y'42)/&a/0.e©AJc,'An-o, ., Title Telephone No.(business) Telephone No. (cell) e-mail address If a licable,the property j'ner hereby authorizes: e m y 141 KW -7 IZt Si Y1 d C pa h Gel ' 2.17 So ul. c,t p (U)117-7 Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION Ilk CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) 4 ..1 �-z 7 a -7 .eri7.74�0yom o ed boy 2/1 N Re ' trant) Telephone N-q ail addre Registration Number 01 roar 2 ..0 - ore,77 Ll //Z 2 a Street Address City/Town State Zip Discipline Ex ira ' n Date 10.2 Gener Con actor LS S‘,1° i C Co/7 71,ee,A-z__P •• --)C--__ Company Name BIlly/ Ikc v / o4 2-/j Name of Person Responsible for Construction i License No. Ty Ap 1' ble Street Address CiTown( ' State Zip W-65P 11 5-7 26 2?7 a 37 i-osc 2 p.ze.)e.,)sc-, . ce),-)-7 Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes Cl No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Maten)1sjs Total Construction Cost(from Item 6)_$ 1.Building $ �� V0 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate m ip. _$ . 3.Plumbing $ b , 4.Mechanical (HVAC) $ Note:Minimum i•- =$ contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ i 3 6 00 (contact municipality)and write check number here 15 3f� SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Pe-illy/9),i [kv✓ p -237 ‘c(f7 //z' Please rint sign name l . , �fitle Telephone No. Date 'I ja//2 t'/�..> e l� r 7Z e ,,L1, D/�a( t)Sc'���v c)s< C'Os--, Street Address City/To n State Zip Email Address , 1 J© Municipal Inspector to fill out this section upon application approval: I` . � 14 . 1 4 1 Name s _—te Iaim The Commonwealth of Massachusetts 11,tt l si Department of Industrial Accidents 1 Congress Street,Suite 100 '-�?I-'-" � Boston,MA 02114-2017 •.li. 44. , a www.mass.go►•/dia t: II paters'('umprnsatiun Insurance Affidavit:Builders►I("ontractors1):ketricians.iPlumbers. to tit tIIai)NIIii IHEPER%U INC;A141101111. Aiolkant Information l � � --Cr 67z-dfe2 1 to Pri t_reibis Name tB 'Individtral): (J/� �S r e ,2 c r� Address: // F-74-I i VI K.4..t.) 1Q )c ( - // City/State/Zip: Vim' ,2,, ,..1 y1,�i,���� Phone#: g ` Z_3 7 G 6 3 Aryam .rr'c leek re r.pWe t»�t: Type of pry {(required): I i am a erpkget with S employc'as dull and or peat-tyinc! 7. 0 New construction 201 am a sak au1twk*or puAncridupZIA hate n+cmpintcc*notkenp furst in $. 0 Remodeling ray capacity.(!\a nurkcn'comp easutaet.c rcyear»v1.) 30 I am a htmra.wnct dump all wcrri myxlt )AIo np worriers'cu .mauramc immord.l" 9. ❑Demolition 4.O 1 am a lrtatro.vtnet and trail Ice hiring mcNetratior%to cundutl all murk an my pttrpar y. I weld I O Building addition--+earwte dual all contractor%indict kite nut►rn"ctatp►msation insurance ca arc wk I I Electrical repairs or additives pruptsriun inch au ernpkty s. 12.0 Plumbing repairs or additions 01 am a general contractor and I lime hind the sultcuatraelurs hated can the animated slam Th stdcrutlaat ta e.c . rs hair ctapk.yeea and hat c nurkcr,, ar camp-iaonaae.l 13. f repairs h.� involutionw.e involutiontad to.tdbcar hate efttnrsed then in*oft"- --pet 1NOL c. 14. Ot)tet L'it- I S2.t 1(41.aidws haw as a.,.L, r.)ilia nuricts'cart.albumin rtiqui etti 4 'Any appkcant dud slainben el at oho hit out the neimn ham%bowinilhtir melee'asupaiatrei policy wfansalww. lkntxt,a,a ter who ado*this anion indicating they are dai.i all woad am he.o aside saawaaws Hoist adrii a stet affidavit noising sari kOarracwn that cheep iia hot awn atatt ed as additiitad aloe shswiss ra east Odes adistarar+tct ess d ire whether or not theca aiatras how einplayast Iddm ai►caseraemn haws aafdaymak they sea pouaids dial wwiaa'amp.policy somber. 1 ant an employer that is providing workers"t:otupensation insurance for my eaap a itrs. Below is the polity and job site information. lrtstax),:Company Name: ...... --- ,---- ___&f. (--d //►�/ ' Policy at or Sell ins.Lie.#: ViCi©O 6 024 tI Z?)2 Expiration Date: I/` 9/2Z Job Site Address: 272 Al Si C'ityiStateiZip: )2X -/4/ Attach a copy of the workers'eotwpewtioo piney declaration page(showing the policy number and expire date). Failure to secure coverage as required under MCI c. 152,*25A is a criminal violation punishable by a fine up to SI.500.00 and'ur one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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. I do hereby certify r the ins and naltles of perjure that the Information provided abort is t e a �corrrect. Siiptature: ,� / Dale: /v 4G/ Phone it/'' ' 2 7 6 ? 7 Official use only. Do not write in this area.to be completed by city or town official ('itv or Town: Prtmilil.icease q Issuing Authority )circk one): I.Board of Health 2.Building Department 3.('its'Ivan(`irrk 4.Electrical Inspector 5.Plumbing Inspector IL Other ( untacl Person: Phone 0: 10/06/2021 07 : 03 T-07 : 00 TO: +14135871272 FROM: 4135347874 ACcRD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM'°°"""' 46. ..---.. 10/6/2021 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 CONTACT Sarah Premo NAME: Martin J Clayton Insurance Agency, Inc. { 2 NO EXtC (413)536-0804 (Aic Nej: r1uI534-I871 1649 Northampton Street AOORESS:sprem0@mjclayton.com P. 0, Box 989 INSURER(S1 AFFORDING COVERAGE NAIC r Holyoke MA 01041-0989 INSURER A:Atlantic Casualty Insurance Company INSURED INSURER B: West Side Contractors, Inc. INSURERC: 18 Fairview Avenue INSURERD: INSURER E: West Springfield MA 01089 INSURER F: COVERAGES CERTIFICATE NUMBER:21-22 MASTER 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 NOTtMTHSTANDING 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 ADOL SUER POLICY EFF POLICY EXP'Y UNITS LTRiI/SD WVD POLICY NUMBER (MMIDD Y) J.MMIDDNYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED A _— CLAIMS-MADE X OCCUR PREMISES(Ea Occurrence) S 100,000 L261003720-1 1/20/2021 1/20/2022 MED EXP(Any one person) S 5,000 PERSONAL&ADVINJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE S 2,000,000 X l (f d POLICY ❑ ECROT- LOC PRODUCTS-COMP/OP AGG S 2,000,000 _ OTHER' S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S (Ea accicant) ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS I HIRED AUTOS NON-OWNED PROPERTY DAMAGE S AUTOS (Per acciden:l UMBRELLA LUIB ._-OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S CEO RETENTIONS S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN I ITATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? N I A (Mandatory In NHI E.L DISEASE-EA EMPLOYEE S it yes.describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION (413)587-1272 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PUCHALSKI MUNICIAL BUILDING THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 212 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. NORTHAMPTON, MA 01060 AUTHORIZED REPRESENTATIVE Jeffrey Clayton/EMT I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) 10/06/2021 07 : 03 T-07 : 00 TO: +14135871272 FROM: 4135347874 ACeoR Goo CERTIFICATE OF LIABILITY INSURANCE BATE(MMIDDIYYYY) ie•----- 10/06/2021 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 CONTACT NAME: Fe Trudell MARTIN J CLAYTON INSURANCE AGENCY INC PHONE AAjcji,gx11, (4 13)536-0804 Not: EADDRESS, ftrudell@mjclayton.com 1649 NORTHAMPTON ST RTE 5 INSURER(S)AFFORDING COVERAGE NAICS HOLYOKE MA 01041 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B WEST SIDE CONTRACTORS INC INSURERC- INSURER D: 18 FAIRVIEW AVE INSURERS: WEST SPRINGFIELD MA 01089 INSURER F: COVERAGES CERTIFICATE NUMBER: 703086 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 NAY 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. LTR ._---- ----- ----'----•ADDL SUER'._. -- _.--- I POLICY EFF 1 IPOLICYM/DO/EXP TYPE OF INSURANCE --------._.--____._.._._..- INSD WVD- POLICY NUMBER I(MM/DDM'YY) (MM/DO/YYWI LIMITS i COMMERCIAL GENERAL UABILn'Y ' -- i EACH OCCURRENCE 5 •DAMAGE 10 RENTED I CLAIMS•MADE OCCUR ._. 'PREMISES(Ea occurrence) 5 -__... I MED EXP(Any one person) S__..----- N/AI PERSONAL&AOV INJURY S _GEN'L AGGREGATE LIMIT APPLIES PER: ;GENERAL AGGREGATE S POLICY 1 _ ,,JE a LOC • j PRODUCTS•COMP/OPAGG 5 OTHER: : S .._..___ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ,LEa a ciden9,_ $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED I I SCHEDULED .._...._____....._._.. _.,AUTOS L---- ALTOS N/A BODILY INJURY(Per accident) 5 ' !NON-OWNED • PROPERTY DAMAGE —4— _-- S HIRED AUTOS __ ;AUTOS (Per accident) -- 5 i UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE N/A AGGREGATE S DED ! RETENTIONS I i 5 WORKERS COMPENSATION X PER 'OTH- , ER ANY ROPRIIE CR/PARTNER/EXECUTIVE t 01/29/2022 E.L.EACH ACCIDENT $ 100,000 ,IMantlatory In NH) �� I _... ._........._....___...._.____.__-_..... A OFFICEH/MEMB-REXCUIDEO? NIA N/A � NIA VWC10060245922021A 01/29/2021 �� I If as.describe I NH) E. DISEASE-EA EMPLOYEE S 100,000 I DESCRIPTION OF OPERATIONS below 1 E.L.DISEASE-POLICY LIMIT $ 500,000 NIA I DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remade Schedule,may be attached it mom space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue dale of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PUCHALSKI MUNICIPAL BUILDING ACCORDANCE WITH THE POLICY PROVISIONS. 212 MAIN STREET AUTHORIZED REPRESENTATIVE kl NORTHAMPTON MA 01060 Daniel M. L ro . D .Crdw)ey,CPCU,Vice President-Residual Market-WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD City of Northampton /r Massachusetts * e DEPARTMENT OF BUILDING INSPECTIONS W � ,' 212 Main Street • Municipal Building Northampton, MA 01060 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: 7 l( (0 m� it, nis n� cl Location of Facility: �t'� f/` The debris will be transported by: je Ile ,70,' ef,/ Name of Hauler: Signature of Applicant: Date: 1 ) "13- \�T 0 c) a � c_ `K- a/b'� /2/l�sl�� l 2.5 CI:11:1:14°15 d