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18D-001 (6)
Versionl.7 Commercial Building Permit May 15, 2000 Department use only City of Northampton Status of Permit: Building Department . CuUDrveway Perm 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413 - 587 - 1240 Fax 413 587 - 1272 Plot/Site Plans 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 This section to be completed by office 1.1 Property Address: p ✓ j Nto�1H QL. 5 �� Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ?AUK DI P rf"'N00 C14 ' bib - iRU T f 0 f)0 ■ 912 3 Sf Rau /-Fz V, 'i'NR Name (Print) Current Mailing Address: 0110 Signature Telephone 2.2 Authorized Agent: 1 ' V 'PPu1J ) 3 0 Jt D V ¶0 = bvEzu &13U 1TA. Name ('rint) i Current Mailing Address: 01103 °r r a -(090 0 \ 13D Signature Telephone SECTION ES P M TED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building i} � 03 O/ (a) Building Permit Fee }� 1 2. Electrical �l 00 (b) Estimated Total Cost of 'f U Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) $5)400, Check Number Lt 3 . This Section For Official Use Only BuildingNur j Date kik) Issued ( Signature: Building Commissioner /Inspector of Buildings Date Versionl.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 ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other Brief Description Enter a brief description here. Of Proposed Work: Y kVP 'K {,! f IT4 E V 1,'P u I gE1 ' 1Z y �� 1 O1 G D VI LDI1) & SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ 5-1 ❑ S -2 ❑ 5B I ❑ U Utility ❑ Specify: t 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: Proposed Use Group: 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 (sf) 15t 1 St 2nd 2 nd 3 rd 3 4th 4m 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 ZoneD Municipal ❑ On site disposal system Versionl.7 Commercial Building Permit May 15, 2000 8. 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 1.6 -0 Bldg. Square Footage 13 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 DONT KNOW 4 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 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 Obtained , Date Issued: C. Do any signs exist on the property? YES j: NO IF YES, describe size, type and location: a.i ' \<%30,J1.) D. Are there any proposed changes to or additions of signs intended for the property ? YES (3 NO A IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO wV 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 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 Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor d� p nc' C \FJOOL \V (iow\V t • LSC #�0�4 IJ Not Applicable ❑ C Company Name: G )kc, I I1Lf''ad l R: ..nsible In Chan e of Construction '0 0 (O1 1 O b)11-1Q1-1-0‘\/ ; ►gip 01103 Ad r4141111 Signature Telephone 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 0 No SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date , 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 under the pains and penalties of perjury. Print Name Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Na of Licen Holder : 3 ° J 1- C • VI; OO1 �pS 1 a License Numb r M P'k t i 113 -� ' 01 ) \1) � I uL -� ' 'A. 01103 03 0 201 Andress i nell Expiration Date Signs' � Telephone SECTIO 1 -WO' ERS' 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 0 E- ,il,,_)y ,,,4, , , - A CH ' is ' ' - • - . it,:iq_-;,..__,,:,.. ,_ II ei't hv,...*':°21',....sit. • .... '' t"' ..' ' 9 - : MBHR 1SS � � GNU i l'''cOrtikviERerAuvii 14 c . 0 , , , ,,-,. , - . - r . '' .131420425 i ' j Sr M3 p :" - ' 3 -0840 ' s . . , � F �r f?AN,OOLFP q' RH ty ir'1 � i4G UF14I :i ' 01'9' \ o ° s yw,,�5 ,-s ! t i 01$03 - 1 ' Nlu•Nachu.ctt• - Ucl''artrtrcnt of Puhlic 'NA t 7' j Board rrf Builtlirp RC�2ulutiun. art(' �t:rr;uurr1• -1 Construction Supervisor License License: CS 6892 Restricted to: 00 JOSEPH P PANDOLFO 3 MEADOWCROFT RD BURLINGTON, MA 01803 Gi - Expiration: 3/8/2012 t •nurri,,i 'i,t r Tr= 19921 U lm (c rn cvivaea/h' o/✓ sar %uceeita Office of Consumer Affairs & 13 .siness Regulating! ng! t -- -‘- TUB_ G HOME IMPROVEMENT CONTRACTOR • _`,_ 11---=---.5, Registration: 113748 Expiration: 7/14/2011 Tr# 289475 , Type: Private Corporation • PANDOLFO CO INC JOSEPH PANDOLFO 3 MEADOVI/CROFT RD�s —-- BURLINGTON, MA 01803 Undersecretary ACORI CERTIFICATE OF LIABILITY INSURANCE ) 05/26/2010 PRODUCER 978 - 433 -2728 FAX 978 - 433 -8658 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Brown & Brown of N H, Inc . ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 3 H o l l i s St ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P 0 Box 1497 Pepperell, MA 01463 INSURERS AFFORDING COVERAGE NAIC # INsuRED Pandol fo Com Inc. INSURER.A Acadia Insurance Company 31325 3 Meadowcroft Rd. INSURERS Firemen's Insurance Co of DC 21784 Burlington, MA 01803 -1019 INSURER INSURER D INSURERS - -��_ -- COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR H DD' PO EFFECTIVE I PO EXPIRATION L?B ■ . I — _ _ TYPE OF INSURANCE POLICY NUMBER LIMITS T) ( MM /D n1YY j DAT E (MMIDDIT � GENERAL LIABILITY CPA0100280 -16 01/01/2010 01/01/2011 FAI_AERHENCE S 1,000,000 )AMA 10 RENT: -E X (... L L' ENE RA' I TABU -I i Y �eFr l I , rT � ,,, a -< °1 S _. 250,000 _OAMS ' MuE J � E ll 0`:,."- MEn EXP (A� nne person) $ 5,000 - -- A _ F a ADV Ir..TURY $ 1,000,000 , GENERAL AGGREGATE 2,000,000 F NE V r-RFrAIFt'MITA ItIFSPER 'IZ<x1IPIS- COMP/OP AGG 5 2,000,000 PL I; Y r 1 1 C 1 L DC AUTOMOBILE LIABILITY MAA0100281 -16 01/01/2010 01/01/2011 ;ME, ..1 SINGLE LIMIT OJT in I _r ,r 0en $ 1,000,000 A JEr> Al, iGS - - - -- _ _ , )/ ) J Y INJURY $ X i _C I, A... er ( sin) X I F [ J ! )y _ )C)II Y INJURY $ X + O,h:ED A'UIOS r'er a�:udent) PROPF R I DAMAGE -- -- i'PI accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ A 'J AWL) A U/U R THAN EA ACC $ AMC) ONLY AGO $ EXCESS /UMBRELLA LIABILITY CUA0100283 -16 01/01/2010 01 /01 /2011 EACH OCCURRENCE 5 6,000,000 _ j OCCU CLAIMS MADE AGGREGATE $ 6,000,000 A $ DEDUCTIBLE l $ RETENTION $ S WORKERS COMPENSATION AND WCA0100284 -16 01/01/2010 01/01/2011 WC STATU- 1011H- EMPLOYERS LIABILITY TORY LIMITS ER 4 ANY PROPRIETOR/PARTNER /EXECUTIVE= E L EACH ACCIDENT $ 500, 000 OFFICER /MEMBER EXCLUDED? E L DISEASE - EA EMPLOYEE $ 500,000 If yes descnbe under SPECIAL PROVISIONS below E L DISEASE - POLICY LIMIT $ 500,000 OTHER ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ERTIFICATE HOLDER _ CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE . l ' - / -d' r��.� �Lc . Cynthia Valiton /CP3 :ORD 25 (2001/08) FAX: 781.843. 8285 ©ACORD CORPORATION 1988 • The Commonwealth of Massachusetts Department of Industrial Accidents i ` Office of Investigations 1 ,5 1, ,., 41 600 Washington Street ,, Boston, MA 02111 4 . = ,t° www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information (� Please Print Legibly N Name ( Business /Organization/Individual): ?\V.YLF C, 3 14 0L • Address: 3 lan3 L Ofl 1RO \O City /State /Zip:b0Z.ZVI 6,-1 , / rav an ZY3Phone #: C\• CIO . q °0 Are you an employer? Check the appropriate box: Type of project (required): 1. V I am a employer with jQ 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6. El New construction listed on the attached sheet. 7. El Remodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. ❑ Demolition for me in any capacity. employees and have workers' working y p ty. $ 9. El Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13. ❑ Other ._ __ _... _ employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1 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: c\ C � S U N► (0' '• Policy # or Self -ins. Lic. #: Jj C \O 1OO ' 1. t:� Expiration Date: 01-0 Job Site Address: VA 11 1\1 (' 'SI RU- City /State /Zip:WM(1\110 ) MR , O 1J 6 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. I do hereby cceer ify u der the ains an • enalties of perjury that the information provi ded above is true and correct. Signature:' J ` QANT , , ' ' Date: 611o11.0 Phone #: r \ C \\ 69 . c\ 10 O \ 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 #: • ACORN CERTIFICATE OF LIABILITY INSURANCE ) 05/26/2010 PRODUCER 978 - 433 -2728 FAX 978- 433 -8658 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Brown & Brown of N H, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 3 Hol 1 is St ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P 0 Box 1497 Pepperell , MA 01463 INSURERS AFFORDING COVERAGE NAIC # INSURED Pandolfo Company, Inc. INSURERA Acadia Insurance Company 31325 3 Meadowcroft Rd. INSURERB Firemen's Insurance Co of DC 21784 Burlington, MA 01803 -1019 INSURERC INSURER D INSURER E COVERAGES 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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR • POLICY EFFECTIVE (POLICY EXPIRATION LT: TYPE. OF INSURANCE POLICY NUMBER LIMITS ■J Bab Di IA GENERAL LIABILITY CPAO100280 -16 01 /01 /2010 01/01/2011 L ACH ocCURRENCE S 1,000,000 X C''MME rZC A i I1t R AI I IABII I C 6 DAMAGE TO RENT; D 250,000 L1 "V. 0 5 MED FXP (Any one > rser) S 5,000 A & AUV INJURY $ 1,000,000 GENERAL AGGREGATE _ 2,000,000 GF r AGCRE I�PLIE S El R ?ROD JCTS - COMP /OP AGG 5 2,000,000 ICI L_) {, - - - - -- - -. — 111 - -- -- -- - - - - -- -— - - -- — - - - -..— AUTOMOBILE LIABILITY MAAO100281 -16 01/01/2010 01/01/2011 r,MBINLD SINGL LIMIT A',Y R! 1T �dentj 1,000,000 A. t ! / C)A -, i(b ill Y INJURY ■Tl X ,,...,.., ( Per person) _ BODII Y INJURY $ X i-1GI ih'V1!EU JILT- !Ger accident) OROPER FY DAMAGE lPer accident) GARAGE LIABILITY AUTO ONLY - EA .ACCIDE. NT $ A TY AU lO O THER THAN EA ACC $ AUTO ONLY AGO — EXCESS /UMBRELLA LIABILITY CUA0100283 -16 01/01/2010 01/01/2011 EACH OCCURRENCE $ 6,000,000 III OCCUR ri CLAIMS MADE AGGREGATE 5 6,000,00$ A ■ DEDUCTIBI. RETENTION $ 5 WORKERS COMPENSATION AND WCA0100284 -16 01/01/2010 01/01/2011 wC STATU- orH- TORY LIMITS ER EMPLOYERS' LIABILITY E . EACH ACCIDENT $ 500 000 4 ANY PROPRIETOR/PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? E L DISEASE - EA EMPLOYE: $ 500, 000 It yes describe under SPECIAL PROVISIONS below - E L DISEASE - POLICY LIMIT $ 500 , 000 OTHER ESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE - Cynthia Val iton/CP3 :ORD 25 (2001/08) FAX: 781.843.8285 ©ACORD CORPORATION 1988