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39A-023 (12) BP-2011-0342 GIs #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP-2011-0342 Project # JS- 2011- 000570 Est. Cost: $2000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MICHAEL L HARRINGTON 102948 Lot Size(sq. ft.): 21344.40 Owner: COMMUNITY ENTERPRISES INC Zoning: GB(100)/ Applicant. MICHAEL L HARRINGTON AT: 441 PLEASANT ST Applicant Address: Phone: Insurance: 611 NORTH ST (413) 575 -8345 WC NORTHAMPTON ,MA01060 ISSUED ON :10 11512010 0:00:00 TO PERFORM THE FOLLOWING WORK.- REPAIR ROOFING,REPLACE SHEETROCK,INSULATION 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 10/15/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner s Versionl.7 Commercial Buildin Permit May 15, 2000 .� se -o City of Northampton Sta ,emu Building Department 212 Main Street re��lal F Room 100 11Uater adali� A <_ (� 10 Not MA 01060 two etsoStro oral Px n y 5 Aone 413 -587 -1240 Fax 413 -587 -1272 Iot/SSt Platas 3 4 , Ott, � Specafji APPLICATION TO CONSTRUCT; - 9 - PAIR, 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 ' � °! �j/( " ✓H �T(1 AJ 1 40 r6 "L i Zone Overlay District -_ Elm St District CIS District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record i✓ldr�l'! Usvt . "_ _..��82� ` 1 _ 7 /.... .L? Name (Print) L t G Current Mailing Address /_nom ...1_m. _.. _^? o d/' d Signature Telephone 2.2 Authorize A nt: Name (Print) Curre Marlin Address Signature Telephone 7 5 5 't SECTIO 3 - E TI ATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building (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 ESY This Section For Official Use Onl Building Permit Number Date Issued Signature: C -�X' ..—Q -)/ I Building CommissiAe Inspector of Buildings Date Version 1.7 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 ZKAdditions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Si ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description Engr a brief descri ti here. 5NC'�; �� 0 dlj Cl�i�tJ aJD Nv2Tis� , �/tt� =C Of Proposed Work:: �I' a 1 1= t l Cf� i (� (3F jLE /►'tlJll +IJUt j'lQ, '7 �� /I-Aj,0 _ u- 'sL) ( --01 SECTION 5 - USE GROUP AND CONSTRUCTION TYPE 2E PA I r- ko N6, j RE Ptq 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 ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B ❑ U Utility ❑ Specify _ ... . _...... d... , M Mixed Use ❑ Specify. S Special Use ❑ Specify:�,u. �,.._.__w.,�..r..._,.� _�,��..a.�...�..�,� .n........®.- �,�,..�.. .._._... COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group _..._. Proposed Use Group: ._..._.__.._ "t! 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 (so .. 1 5f 1 St _ ..... ._, _ b.... 2nd 2nd ;"' ....�.. ,. 3rd 3 rd 4 m 4'" 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 E] Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system[ � - PPuc =� r Al -r r e2 T'�1 �-oo ©> N!1 (R-t`N �'0c2i (0L) or - ry 60 6't �� c r F g ti P Version l.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONIKG Existing Proposed Required by Zoning This column to be filled in by f Building Department (� j Lot Size __..,.._ _,_ __,. ____.,_., M. .__. _._..._. _.__.,, v __ _- .. _...__.. ___ I/D Frontage ,_. _...,_.. _ ____ _ ._.._ . ............ Setbacks Front Side L ___.. _ R. •_-__ Rear _ Building Height Bldg. Square Footage % Open Space Footage _ _ % (Lot area minus bldg & paved p arkin g) # of Parking Spaces Fill: (volume & Location ) _,.. ----- _., A. Has a Special Permit /Variance /Finding e r been issued for /on the site? NO 0 DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 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 0 Obtained , Date Issued C. Do any signs exist on the property? YES NO 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, excavatio 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 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 u 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 j Signature Telephone Expiration Date Name Area of Responsibili Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone I Expiration Date 9.3 General Contractor ._ .__,..__ .... _._...,_ ..___..__..___....__ _..,__.m. _.___._m Not Applicable ❑ Company Name: Responsible In Charge of Construction �( Ct Addr i ure Telephone 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 No Vor SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED_ WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Cr1 as Owner of the subject property hereby authorize fi act on my behalf, in al!/natters re tive to work authorized by this building permit application _ Signature o Ow r J J V Date as Owner /Authorized Agent hereby de lar that the statements and information on the ipegoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains andpenalties of perjury a _. ma _ Print Name Signature of Owner /Age t Date SECTION 12 - CONSTRu6p6N SERVICES 10.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder: License Number Addres Expiration Date Sigq6t r Telephone SE 6W13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit mVet r be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi ermit. Signed Affidavit Attached Yes No 0 The Commonwealth of Massachusetts Department of Industrial Accidents r n s Office of Investigations 600 Washington Street M Boston, MA 02111 f. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): CO 44 11/1 () AJ I 1 f Address: �' x` 5t ' u City /State /Zip: U. - 6 ! V'1 r 6 ' /J 1fi Phone #: C'c> A- r' _t�) Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ 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 g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ P1 bing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. VOth of repairs 13. insurance required.] t c. 152, § 1(4), and we have no 57 employees. [No workers' / � comp. insurance required.] ") % 1 'Ad Sat !! I, *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. r 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. #: rp ✓ 7 Expiration Date: f! Job Site Address: City /State /Zip: ►�-� 7 f`�� / �'` 4' / . 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/ 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 ga' st the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the IA r insurance coverage verification. I do hereby cV'dll pa' and-penalties of perjury that the information provided above is true and correct. Si nature: Date: Phone #: Of 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 #: 13:57 OCT 15, 2010 ID: BORAWSKI INSURANCE TEL N0: 536 -7973 413576 PAGE: 1/3 R Since 1930, serving the Pioneer Valley FAX - --------------- ------------------------------- __----- - ---- ------ - _____- �ow�r I "if It's ksuranm, Ws rCaatta ft"Viffm I 88 King Street, Northampton, MA 01060 To: Michael Harrington Company: COMMUNITY ENTERPRISES INC Fax Number : 586 -1121 Phone Number: From : Irene Balise Fax Number: 413 -586 -7973 Phone Number 413- 586 -5011 Time Sent : Friday, Oct 15, 2010 01:56PM Pages : 3 Description : Certficate of Insurance Michael, Certificate of Insurance for the City of Northampton is attached. Thank you r i acaRa CERTIFICATE OF LIABILITY INSURANCE 10 /lS /2010 PRODUCER 413. 586. 5011 FAX 413. 586. 7973 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Alexander W. Borawski , Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 88 Kin Street, Suite B HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9 ALTER THE COVE RAGE AFFORDED BY THE POLICIES BELOW. Northampton, MA 01060 -3257 INSURERS AFFORDING COVERAGE NAIC # INSURED Community Enterprises, Inc INSURERA: Ace Property & Casualty Ins Co 441 Pleasant Street INSURER B: Northampton, MA 01060 INSURER C: INSURER D: INSURER E: CO 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 ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I T R DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE (MMIDDIYYI DATE fMMMD/YY� GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TORENTED $ IS CLAIMS MADE ❑OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS- COMPIOPAGG $ POLICY PR E CT O LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON OWNED ALTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO EAACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR a CLAIMSMADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WCC46332374 0710112010 07/01/2011 X I WC STATU- OTH- EMPLOYERS' LIABILITY A ANY PROPRIETOR /PARTNERiEXECUTIVE E.L. EACH ACCIDENT $ 500 , 00 OFFICERWEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ S00,00 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500 OTHER DESCRIPTION OF OPERATIONS ! LOCATIONS, VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CE RTIFICATE HOLDER A E N SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, City of Northampton BUT FAILURE TO MAIL SUCH NOTICE SHALL MPOSE NO OBLIGATION OR LIABILITY Attn: Building Inspector OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. Northampton, MA 01060 AUTHORIZED REPRESENTATIVE Robert Borawski/BORIBI �t T ACORD 25 (2001108) © ACORD CORPORATION 1988 cr OCT P- _ • 6 1 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08)