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23B-047 (34)
/ /L \i \ • t/-74 A C� DATE (MNVDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 9/28/2011 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 Shannon Sperrazza Risk Strategies Company ( N ,_�): ( - 4400 FAX 0.(781)963 -4420 15 Pacella Park Drive E-MAIL cam PRODUCER Suite 240 CUSTOMER ID 4 00010691 Randolph MA 02368 INSURER(S) AFFORDING COVERAGE NAIC INSURED INSURER A AmGuard 42390 INSURER B : Diversified Construction Service LLC INSURERC: P.O. Box 168 INSURER D : INSURER E : Belchertown MA 01007 INSURERF: COVERAGES CERTIFICATE NUMBERCL1171139063 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 ADM SUBR POLICY EFF POUCY EXP LTR TYPE OF INSURANCE INSR WVD POUCY NUMBER (MM/DD/YYTY) (MM/DD/YYYY) UNITS GENERAL LIABILITY EACH OCCURRENCE $ _ DAMAGE TO RENTED $ COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) CLAIMS -MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY _ $ GENERAL AGGREGATE $ GEML AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ - 1 POLICY JET LOC $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON -OWNED AUTOS $ UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION DIWC122619 10/28/201010/28 /2011 g WCST AT OT ER AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N Partners are excluded E.L. EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? I Y N/A f ro m coverage (Mandatory in NH) 4 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 (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Issued as evidence of insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Smith Vocational and Agricultural High Sc ACCORDANCE WITH THE POLICY PROVISIONS. 80 Locust Street Northampton, MA 01060 AUTHORIZED REPRESENTATIVE Michael Christ /KIL ---- -- Department of Industrial Ar'riients - `t �—�=Qi ,� Office of Investigations =:7, , .;, • 600 Washington Street - Boston, MA 02111 ..,- wwH.mass.gov /dia Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): i Ve -,,• , Ct rs Al Al(n 0 1'tQ.h. i L L - Address: fps `]nit ),(5( • City /State/Zip: a & ("-Af" 1 *;, 6'06 t- - Phone. #: 0 '13- '-moo Are you an employer? Check the appropriate box: 1. ' i am a to with 4. Q 1 am a general contractor and I Type of project (required): �� 6. 0 New construction employees (full and/or part-time).* have hired the sub contactors 2.0 I am a sole proprietor or partner- listed on the attached street. 7. 0 Remodeling ship and trove no employees _ These sub - contractors have 8_ ©Demolition working for ere in any capacity. employers and have workers' 9. addition [No workers' comp. insurance comp. insurance.$ 0 Building required.] - 5. We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL M Roof repairs insurance required..] t c. 152, § 1(4), and we have no employees. [No workers' 13 Other &VIC t11SAA∎ comp_ insurance required] * Any applicant that checks box #1 rrntst also fill out the section below showing their workers' compensation policy information. . t Homebwners who subrrat this affidavit inicating they are doing! work and then hire outside contractors must submit a new affidavit indicating such. IC-ontrectors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether ornot those citifies 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: � �, ` 1 $ 0 ( 'nP Y L U� Policy # or Self-ins. Lie. #: � C I ("42:1- Expiration Date: Z ( it J o b Site Address: t L LC -V'Sr 5: 01:54-110)0447:0K) C i t y / S t a t e / Z i p : OVA l ()\ O( 0 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/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification- / do hereby certij, under the pains and penalties ofperjury that the information provided above is true and correct. Si In ature: .11.1 Date: • ZZ 1 1 Phone #: i? :. C T - Z (; (/ - Official use only. Do not write in this area to be completed by city or town official City or Town: # Issuing Authority (circle one): 1_ Board of Health 2. Building Department 3. City/Toivn Clerk 4_ Electrical Inspector 5_ Plumbing Inspector 6.Other - Contact Person: Phone #: Google Maps http: / /maps.google.com /maps ?oe= utf- 8 &rls =o.. To see all the details tha are visible on the �F V )1c. rn a p screen, use the "Print" link next to the map. y y� lif t% k i 31 >R't',,y z .,i p' it 'Add � R "� ` f If du M ■ y . x r r Y � i t +I 4 x s '^ ' fir " �'4` �tl(Yi .�1 • +� �* a � [1 kin5u� ■ r • ''fit E #w `x. '+ 4 ip '-�u .,:;l ° / �r . ., , , topi, - , e , v i ll } ,. 4"b w `, " ' • s 4,. w �. r �+71 f ' p iM A. b '$ JI f ,' �...v: 1 of 2 9/28/11 12:03 PM Version1.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes ® No 0 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT f- 1402. 4 S,`c, L , as Owner of the subject property hereby authorize 17 to act on my b alf, in all m.' -rs relative to work,, thorized by this building permit application. / ( / ( e ( Signature of Owner ` Date ika lr An_ >o l k-v , 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 nder th pains d penalties of perjury. Print N Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : C 0 V 'L1 30 $1 License Number l oo U w e Jc s ) PI \ �i2Sr N c o'Oc L ' [ LO 20 v3 Address Expiration Date � 6 Sign r - 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 No . 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): /11_ Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): 17.62' N J C� ame, Area of Responsibility t k_a S o 1 ' D(Z- - VkA9 U ` I I A p l C.)3‘. 316 I `7 Address Registration Number qt3 537-14 30- (-- Signature Telephone Expiration Date Name Area of Responsibility N1 Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility 7\1 / A Address Registration Number Signature 9 Telephone Expiration Date Name /A-- Area of Responsibility Address Registration Number Signature Telephone p Expiration Date 9.3 General Contractor 17tVeY1 /V S c-rt Not Applicable ❑ Company Name: Responsible In Charge of Construction t of U N 2 S e Cl t7,'.VC 1 1-k)tS al A 0( 60 Address Signature L I t 3 5 21co Telephone n i Version1.7 Commercial Building Permit May 15, 2000 S. 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: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) _ # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW g YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T 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 ® DON'T KNOW e YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: (4 wk... S L C m vt-w Ekt2 ANGt D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO 41* IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, exc vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • C,+ i- , JL rL a 94,I1- G,F yolk-el 14(1 0) fa TH 51 j tiScti 6, CO V 1 I (z) rov (2) 12A.L% r CZOnt- RctAt_ed v- 1a (I) yolcC � ANA.h (4) SO t. P .Jets Si ithn l. F"wv> prCt W) � R pa-n 0 f i� s ' Version1.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 Ai 6t��. -cSY� 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 XI Brief Description Enter a brief description here. Co l� $t'f1('c. r 66 5501 PA- c�r L /4' L ' , � ' ` c1 w.. iS-t"iAl6 o4t- nlr7'f6�1,t�7W W , 1vt.: `Ft N��F Vc'2rtc Ft ‘...e7 i 'r (L{) to Finis l a ACS ILs , ,,,,, Of Proposed Work: ,t rot 00 of Elko, P" t.. A1/44.5*- Da.v s- Ftrt t l am rue 61)4:W O, SP no k r-c 1 ' lt)4x SpAt4t WI. 1i Fst =am- PA-J1& C...JS«ms, -.A CLUk . SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational 4 2B ( ❑ 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 ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B [ ❑ 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: i f I 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) ` i / IA � 1 st 1 st 2nd 2 nd 3 3 rd rd 4 th 4 th 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 A I x . j 1.. ..:w .M... ■ Version 1.7 Commercial Building Permit May 15, 2000 Department use only • • k • • • - •• • • • Status of Permit: B I i_ T C Curb Cut/Driveway Permit 12 Main Street Sewer /Septic Availability UPI Water/Well Availability o ampton, M 061 Two Sets of Structural Plans phone 3 -�, , - ,,,;_, 87 1272 Piot/Site Plans NORTHAMPTON, MA 01060 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 SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office gU (--cCu r ' Map Lot Unit 0r2- r14 AVM Pre/1/41 if) Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: yy II TZ65i i 7 civs l r tt Vo erwrio. k'sh. 411/4(- 0.0 g Loco s ►Jaa r kivt p n n i /140 O Io ( Name (Print) u 11s Sc-1:460..9 Current Mailing Address: 41'3 551 lt.}04 k 3406 Signature Telephone 2.2 Authorized Agent: Aken4 U2 ! ?)St"oLt C Lec oS. rxice_ tAMp Tor", M a 0 lot.° Name (Print) / Current Mailing Address: I ' 3 5 �7 t 1 pc 3 �for� • Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 1 ©t ©L) (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of 1 5 000 Construction from (6) 3. Plumbing Building Permit Fee — U 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) "Z 00c, Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0466 APPLICANT /CONtACT PERSON DIVERSIFIED CONSTRUCTION SERVICES ADDRESS/PHONE 100 UNIVERSITY DR AMHERST (413) 549 -2900 0 PROPERTY LOCATION 80 LOCUST ST MAP 23B PARCEL 047 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out C5C15-A 0 Fee Paid Typeof Construction: SOLAR INSTALLATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 030787 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9I MATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER: § Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay //b/L---9 //(213/1/ Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. 4 � _ 1 80 LOCUST ST _ • BP- 2012 -0466 GIS #: • COMMONWEALTH OF MASSACHUSETTS Map:Block: 23B - 047 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: CITY -NO FEE BUILDING PERMIT Permit # BP- 2012 -0466 Project # JS- 2012- 000763 Est. Cost: $28000.00 Fee: $0.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DIVERSIFIED CONSTRUCTION SERVICES 030787 Lot Size(sq. ft.): Owner: Smith Vocational & Agricultural High School Zoning: Applicant: DIVERSIFIED CONSTRUCTION SERVICES AT: 80 LOCUST ST Applicant Address: Phone: Insurance: 100 UNIVERSITY DR (413) 549 -2900 (Q AM H E RSTMA01002 ISSUED ON:11/28/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:SOLAR INSTALLATION 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 11/28/2011 0:00:00 $0.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck— Building Commissioner