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PEC #4389 GC Change Request 10.31.22 28 Station Street Manalapan, NJ 07726 Phone: 732-786-2484 Fax: 732-617-6966 October 31, 2022 Town of Northampton Building Department ATTN: Kim Carson 212 Main Street Northampton MA, 01060 RE: Change of GC Request for BP-2022-0967, 1 King St. Dear Kim, Please accept this letter as a formal request to change the general contractor on this permit from DF Pray to AmConCorp. Attached please find the following documents: • Check for $25 made out to City of Northampton • MA - Workers Comp Affidavit • COI – certificate holder: City of Northampton 212 Main Street Northampton MA 01060 • MA – GC Construction supervisor’s license • MA – Construction Control Document If you could please email a copy of the new permit to me at afitz@peconsultingcorp.com, and the hard copy to my attention at the address below I would greatly appreciate it. Project Expeditors Consulting 28 Station Street Manalapan, NJ 07726 Thank you! Andy Fitz Regional Team Lead New England The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):______________________________________________________ Address:__________________________________________________________________________ City/State/Zip:_____________________________ Phone #:________________________________ *Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information. †Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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 the policy and job site information. Insurance Company Name:____________________________________________________________________________ Policy # or Self-ins. Lic. #:__________________________________________ Expiration Date:____________________ Job Site Address: City/State/Zip:______________________ Attach a copy of the workers’ compensation policy declaration page (showing the policy number and expiration 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: 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 #:_________________________________ Type of project (required): 7. New construction 8. Remodeling 9. Demolition 10 Building addition 11. Electrical repairs or additions 12. Plumbing repairs or additions 13. Roof repairs 14. Other____________________ 1. I am a employer with _________employees (full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers’ comp. insurance required.] 3. I am a homeowner doing all work myself. [No workers’ comp. insurance required.] † 4. I 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 proprietors with no employees. 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers’ comp. insurance.‡ 6. We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers’ comp. insurance required.] Are you an employer? Check the appropriate box: 10/27/22 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 10/21/2022 John McLaughlin Agy 828 Lynn Fells Pkwy Melrose MA 02176 781-665-2775 781-665-0295 info@mclaughlininsurance.com Ohio Security Insurance Co 24082 AMERI-4 Liberty Mutual 24074AmericanConstructionCorp. 3 Mount Pleasant Drive,2nd Floor Peabody MA 01960 Travelers Prop.Cas.Co.of Am 25674 1686037299 A X 1,000,000 X 500,000 X Contractual Liab 5,000 1,000,000 2,000,000 X BKS58662622 4/1/2022 4/1/2023 2,000,000 NO DED/SIR A 1,000,000 X X X BAS58662622 4/1/2022 4/1/2023 C X X 5,000,000CUP1S3353974/1/2022 4/1/2023 5,000,000 B XXWO5866262211/9/2021 11/9/2022 1,000,000 1,000,000 1,000,000 A Inland Marine BKS58662622 4/1/2022 4/1/2023 Leased/Rented Equip 25,000 City of Northampton 212 Main Street Northampton MA 01060 2 Kayla Nassar Principal C. (857) 225-5465 O. (781) 584-6178 www.amconcorp.com 1 Laurie Boucher From:Kayla Nassar Sent:Sunday, October 16, 2022 10:33 AM To:Laurie Boucher Subject:Kayla CSL Version 01_01_2018 Initial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the ninth edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Date: Property Address: Project: Check (x) one or both as applicable: New construction Existing Construction Project description: I MA Registration Number: Expiration date: , am a registered design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning1: Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project and that to the best of my knowledge, information, and belief such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official, I shall submit field/progress reports (see item 3.) together with pertinent comments, in a form acceptable to the building official. Upon completion of the work, I shall submit to the building official a ‘Final Construction Control Document’. Enter in the space to the right a “wet” or electronic signature and seal: Phone number: Email: Building Official Use Only Building Official Name: Permit No.: Date: Note 1. Indicate with an ‘x’ project design plans, computations and specifications that you prepared or directly supervised. If ‘othe r’ is chosen, provide a description. JPMC Northampton Date: 08/03/2022 1 King Street, Northampton, MA 01060 1st fl. renovation of the existing building to support the proposed new JPM Chase Bank Plumbing & Fire Alarm MA Registration Number: Expiration date: Robert Leber 36457 617-748-7800 RLeber@cosentini.com