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32A-143 (24) BP-2022-0242 36 MAIN ST FLoR ,rcer COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 32A-143 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-2022-0242 PERMISSIONIS HEREBY GRANTED TO: Project# RENOVATION Contractor: License: Est.Cost: 1300 ADAM CLARKE 102048 Const.Class: Exp.Date:08/07/2022 Use Group: Owner: COREY LYNCH Lot Size (sq.ft.) Zoning: Applicant: ADAM CLARKE Applicant Address Phone: Insurance: 1066 GRANVILLE RD (413)219-5860 WCC-500-5009653 WESTFIELD, MA 01085 ISSUED ON:03/22/2022 TO PERFORM THE FOLLOWING WORK: PARTITION WALLS 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: Gas: Final: Final: Rough Frame: Rough: Fire Department Driveway Final: Fireplace/Chimney: Final: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: '4,1 >2 - I 33 Fees Paid: $100.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner Ma 2022 fi i The Commonwealth of Massachusetts 0 ' . Office of Public Safety and Inspections .._ __) Massachusetts State Building Code(780 CMR) ' +•,4it Pn r e�eTi Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number:oZ 2. 24/.). Date Applied: Building Official: SECTION 1:LOCATION .3(O tt ed " VAa:ovSt . CIQrunLe— 1MA cU\,2 Drawtn ld �ckvrr(west- C ,. . No.and Street Ci /Town Zip Code Name Building(if applicable) J Assessors Map# Bock#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 GI/ Repair 0 Alteration 13/ 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 Peer Review required? Yes 0 No 0 Brief Description of Proposed Work: co—vvw.Q Z k n}e. X1.cK 7aAS ki,o h ♦-k \\,5 w 9 (0 tsAg-c.X c- AS . 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) 0 Existing Use Group(s): N d C..,‘,-,cAlvvr --C_ 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❑ 1-4❑ M: Mercantile 0 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 0 IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV 0 VA 0 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: Public 0 Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site 0 Private 0 or indentify Zone: or on site system 0 required 0 or trench or specify: permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 0 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 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 Name and Address of Property Owner C y n LNr, 3d 0 0 . J QS a te ask. , a.,. I 0-1f it o ��k Name t)1 No.and Street City/Town Zip Property Owner Contact Information r-t�lp� ��- - cp523 = - drawt Agboarsl�hr�w►A�co Telephone No.(business) Telephone No. (cell) e-xifail address c m& t, co' If applicable,the property owner hereby authorizes: Adorn a\o. k_e_ lubp C.nyr rsv:t (R-d. WQ.S clerk Ott isS Name Street Address City/Town State 1 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 10: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 0/ 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) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor AcicArn C10,�t e - -P C laru_ Car G on \nL. Company Name Marn C'la►r t.-e__. C s- t o to Li5s /(1_ I U Name of Person Responsible for Construction license No. and Type if Applicable 1v b(a Groan:11_aI• 10e_s 2,1c1 O vl08 S Street Address City/Town State Zip L -5ii 5-240 3 41. -1 °_.I_- 5`6100 adaytn P a clay _C c> v-vck\or ,L ot", 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 ' uance of the building permit. Is a signed Affidavit submitted with this application? Yes ' No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ I p O a.,` 1 3 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate m •:•al facto =$ (00 . 3.Plumbing $ 4.Mechanical (HVAC) $ Note Minimum f•.—$ ' contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ \ 2,00 . v (contact municipality)and write check number Sete 01�CO 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 of my knowl e and understanding. Uri 7( -s 4 3 311)2072- Please print an sign name Title Telephone No. Date f iges rbt 1 auto ��cr�,z16r (L Q V,) r ietci H A- OI Q S QStkeq e a[facto C(.>%Sivi...CricYN r mow., Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: ///e "•Z2-ZO2 Z Name Date City of Northampton ".,- � 1 Massachusetts ���s c,�` : it DJ .0 « 1 DEPARTMENT OF BUILDING INSPECTIONS 1. •r' ` " 212 Main Street • Municipal Building J h i ! � Northampton, MA 01060 j441, .��^Jc 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: polo o to Cerc rw c lk- . /� Location of Facility: l AMAyvc for 1)v w,,p E UJes- etct Hik- U%v f 5 The debris will be transported by: Name of Hauler: -2y1".- Sti\I i.L.P,..S Signature of Applica : Date: 31 1 P-2 t)Z2 The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street.Suite 100 Boston.ALA 02114-2017 www.mass.gov/dia 1%urker.'Compensation Insurance AiTrda%it:Buildersi('antracturs+'ElectriciansTlumbers. 11)BE FILIF_D 111'111 111k:PEKSIiI I IN(:At I NOK111. Applicant Information ►.,� Please Print 1_reibh Nifine(Business Organization Individual b: C)CA.r - V\C_ . Address: I ub(e ( r - i Alt >Zc . City/Statdzip: VO IL-S4 AcJ H ft 6 i o&5 Phi# u 3 S 1 - S3.y 3 ..trr you as_ ;e?Cbetik the apprepriaic Wu: T)pc of project(required): 1.2(1am a otipkirt with a CO rnnpluyecs(full mawputel-t7imtl• 7_ —�New` construction _s. l as a milt paoprirhn or piulncaship and hate no erstpMr�yeeo.working In me on $. 34ci modeling any capacity.[No"hurler.'cutup.n ntrmsura ayurnd_I lL 77 9. ❑ Demolition _. I am a htnTretitwncr Clowns all work mtsel1 INo workers'cunt.,uisuranoc nt(Wrczl.l• 4.0 I am a homeowner and will be luring couuractun pa conduct all work on my pntp rty.. I well 100 Building addition canon that all contractors otter hate wt,r►ers.'compcmalnun uc+ura ce oar air wide no Electrical repairs or additions pre,pTeelt,Ps w1lh no crtmpluycea. 12.0 Plumbing repairs or additions I am a general ct,ntraclt r and I Irma hued the.subrxmuact,ra lewd ns the attached sheet. 13.0 Roof repairs Thew: The sub-ccxntractors hate cergsJuyccs anti hate workers'comp.to urance I L p ^ '"t__)Wit arc a ca.rp+Aralotm and Ito.utTiccrs hat c eaucxsed risen mold of exemption par�t(iI.c. _ 14.�lthei 152.11(4t.and we hate no emploweca.tNtn worker.'comp-rnturance rewired" U S *Any applicant that chc.ks IN..-I muse also fill out the scctnrtn l+cluw showrm:them worker s catrarpcntatiun pntlirV infonllttiem. t Itstrr cownen whin'Anna this attittat at mhcalone the!,arc dot inc all work and then hie mtutardc to ntrachocs must submit alrDwtlttlaasit urtet.akn r stt-h. kamtractt,rr,that check thin benx mutt attached an aldrtxnnal sheet auto now:the name of the sub-ctwrtract.,rs ant!.Cate whether ar■Otdansc empties hase ernpluyccs. It the sub.tontrackws hate m-n,k,ytnca.they must moult:thcrr worker. comp_polrc.number. I am an employer that is providing w•orlters"compensation insurance for my employees_ Below is the policy and job site information_Insurance Company Name:_(r �o � kyNS • A cyjr c_N_ — Policy#or Self-ins.Lic.#:_Y�1CL-SOO- 6 OO 9 toj 3-2_CYLAIA Expiration Date: V2'Ct Job Site Address_ 3 _____ City.+StateiZip: Oc_o---C.2. _1-1PI O\()IO2 Attach a copy of the workers'compensation policy declaration page(showing the policy number sad espir Lien date). Failure to secure coverage as required under MGL c. 152,*25A is a criminal violation punishable by a fine up to S1,500.00 andlor one-year imprisonment.as well as civil penalties in the form ofa 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 verttut::tttan I do hereby certify nder the pains and pe hies of perjury that the information provided above is true and correct Si mature: liatc 9 I'2_c)2Z Phone#: LI 1 � chl - 534 3 Official use on/c. Do not write in this urea,to be completed by city or town oficial ( its or Toon: Permit/License# Is.uing Authority (circle one(: 1. Board of Health 2.Building Department 3.City flossn Clerk 4.Electrical inspector 5. Mouthing,Inspector b.Other Contact Person: Phone#: /1 &Oarca e.\-e,.a C , 3(o c)44\1. v✓l c1 sT -l6ce ,-2ce �L1g C°° Astr 9'64 bor V to t ),r,r,,t 10 ()co-11-w) \ w•�� 2k-'4 skya Tall I( " o f ccwycr 31` Lo'S‘C CSL Cc -d The Official Website of the Executive Office of EOHED, the Divsion of Professional Licensure,and the Division of Standards '—& Public Safety 01 le 1 -. • Mass �Mass Gov Home State Agencies Licensee Details Demographic Information Full Name: ADAM T CLARKE Owner Name: License Address Information City: WESTFIELD State: MA ipcode: 01085 Country: United States License Information License No: CS-102048 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 7/7/2020 Issue Date: 3/31/2009 Expiration Date: 8/7/2022 License Status: Active Today's Date: 3/9/2022 Secondary License Type: Doing Business As: Status Change Reason: License Renewal Prerequisite Information N o Prerequisite Information No Available Documents Close Window I ©2011 Commonwealth of Massachusetts Site Policies I Contact Us AC� DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3/9/2022 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 CONTACT NAME: Mary Benjamin Greylock Insurance Agency PHONE _ FAX PO Box 603 Lac,No.E t) 413-729-6090 (A/C,No):413-568-6708 E-MAIL Pittsfield MA 01202-0603 ADDRESS: mbenjamin@greylocic.org INSURER(S)AFFORDING COVERAGE NAIC A License#:1803779 INSURER A:Arbella Mutual Insurance Co 17000 INSURED ACLARKE-01 INSURER B:Arbella Protection Insurance Co 41360 A Clarke 66 INSURER Granville Road Construction Inc 1066 RERC:Associated Employers Insurance Co 11104 Westfield MA 01085 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:570125966 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 ADDL SUBR POLICY EFF POLICY EXPM/ LIMITS LTR INSD WVD POLICY NUMBER JMDD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY 9520108576 6/13/2021 6/13/2022 EACH OCCURRENCE $1,000,000DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY JECOT- LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER. $ B AUTOMOBILE LIABILITY 1020038629 2/20/2022 2/20/2023 COMBINED SINGLE LIMIT $500,000 (Ea accident) - ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILYINJURY(Peraccident) $AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLAUAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ OTH- C 'WORKERS COMPENSATION WCC-500-5009653-2021 A 12/9/2021 12/9/2022 X STATUTE ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? Y NIA - (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $100,000 I If yes describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I 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 ACCORDANCE WITH THE POLICY PROVISIONS. City of Northampton 212 Main Street Northampton MA 01060 AUTHORIZED REPRESENTATIVE firs, it Xs►-r***--- ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD