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18D-028 � �:.. L . {:, g < \ � 4 \ \ if \ ''''''''''''''''''„''s;' 4. i. \ \ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization /individual): 1)30,--.;\ 3 -,30 C - \(fir , Address: t k3( n kC>n '3• • 1 3 c x \c-)55 City /State /Zip: "R , U : _ r Phone #: k�13 ?>T - 611 Are you an employer? Check the appropriate box: Type of project (required): 1. I am a employer with a5s 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 8. ❑ Demolition working for me in any capacity. employees and have workers' g Y p h 9. ❑ 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 12.111 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13. ❑ Other 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. *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. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: P\m (no \ Qocp Policy # or Self -ins. Lic. #: ,aS`fZ'' ?)51 tacmic) Expiration Date: �\ a \ ae' y Job Site Address: ] or- \ `l (yfa 3k-cee It City /State /Zip: le c 1 CO 11 01C(DO Attach a copy of the workers' compensation`pl licy 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Si nat� Date: 101 al \ t© Phone #: 'k\ - 3A - 7 \ 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 #: ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ODNYYY) `,,..•+'' 6/3/2010 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 James J. Dowd & Sons Ins PHONE FAX 14 Bobala Road (aC�No. Ext. 413- 538 - 7494 (ac,No):413 -536 -6020 P.O. Box 10300 E AODRESS: Holyoke MA 01041 PRODUCER CUSTOMER 10 B. _ INSURER(S) AFFORDING COVERAGE NAIC A INSURED INSURER A : Travelers Agnoli Sign Co., Inc. INSURER B:A.I.M. Mutual Insurance Company 33758 722 Worthington Street PO Box 1055 INSURER C : Springfield MA 01101 -1055 INSURER D: INSURER E : INSURER F COVERAGES CERTIFICATE NUMBER: 1353177599 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 AWL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DDIYYYY) 1MMIDOIYYYY) LIMITS A GENERAL LIABILITY 6309496A387 6/21/2010 6/21/2011 EACH OCCURRENCE $1,000,000 COMMERCIAL GENERAL UABILITY DAMAGEaENTED PREMISES S ( RENTED Ea .$100,000 CLAIMS -MADE [X IOCCUR MED EXP (Any one person) 35,000 PERSONAL & ADV INJURY 31,000,000 GENERAL AGGRE-GATE 32,000,000 GEM_ AGGREGATE UMIT APPLIES PER: PRODUCTS - COMP/OP AGG 32,000,000 POLICY IF .T- LOC $ A AUTOMOBILE LIABILITY YA08106567C813 6/21/2010 6/21/2011 COMBINED SINGLE LIMIT 31,000,000 (Ea aociders) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per aocidenl) 3 X SCHEDULED AUTOS PROPERTY DAMAGE X $ HIRED AUTOS (Per accident) X NON -OWNED AUTOS .3 • X $ A UMBRELLALIAB X OCCUR CUP6567C813 6/21/2010 6/21/2011 EACH OCCURRENCE $5,000,000 EXCESS UAB CLAIMS-MADE AGGREGATE $5,000,000 DEDUCTIBLE $ X RETENTION 310,000 $ B WORKERS COMPENSATION W/8003518012010 6/21/2010 6/21/2011 X IT OT ER AND EMPLOYERS' UABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE I v N / E.L. EACH ACCIDENT $1,000,000 OFFICER/14EM3ER EXCLUDED? N / A (Mandatory In NH) E.L. DISEASE -EA EMPLOYEE 31, 000, 000 If yes, describe uncle( DESCRIPTION OF OPERATIONS bebw E.L. DISEASE - POLICY UMIT 31, 000, 000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) *20 Days on Automobile and 10 days on Workers Compensation for non - payment. 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. AUTHORIZED REPRESENTATIVE R ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD OF 11. ALL INFORMATION MUST BE COMPLETED; PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION. 12. This column to be filled in by the Building Department. Existing Proposed Required by Zoning Lot Size Frontage Front: Setbacks: Side: L: R: L: R: Rear: Building Height Bldg Square Footage % Open Space: (Lot area minus bldg and Paved parking) # of Parking Spaces # of Loading Docks Fill: (volume & location) 13. Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. DATE: v.,) a'- io APPLICANT'S SIGNATURE NOTE: Issuance of a zoning permit does not relieve an applicant's burden to comply with all zoning Requirements and obtain all required permits from the Board of Health, Conservation Commission, Department of Public Works and other applicable permit granting authorities. FILE # Page 3 of 3 THIS FORM IS PART OF THE SIGN PERMIT APPLICATION File No. ZONING PERMIT APPLICATION PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant: '(q3nCIA ∎ �, q� ( c� \ CY' C)101 tO5b Address: PO 6-)/, InJ� �c',r{{ �pk'� e) Telephone: 1 -11: - 5111 2. Owner of Property: u e r F\ 6 , OnP \ I J \f'5, }c c : rY "Q �►ol Address: 7,x Ih K, r �\ nr \1 CZ rcr1M1, rn A Telephone: 3. Status of Applicant: Owner ✓Contract Purchaser Lessee _Other(explain): 4. Job Location: 6 r ; 1n \\ % c'C'; \ ref E Parcel ID: Zoning Map # Parcel # District(s) (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Existing Use of Structure /Property: \c\5.,c (Icy P ( 6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary) V E=A,3V, T', 3c) r,c) bI— \c n J �.;; >r--' (' nrJ ��s 'A ' A 30' , IP A. . '3\t 7m (1a1erl no or pc lPkket -1(1C; (Z'cl le Ann VCc_P_ C4r hc-C\ Ch• 7. Attached Plans: 7 Plan Site Plan Engineered /Surveyed Plans 8. Has a Special Permit/Variance /Finding ever been issued for /on the site? NO ✓ DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES: Enter. Book Page and/or Document # 9. Does the site contain a brook, body of water or wetlands? NO / DON'T KNOW YES IF YES: Has a permit been, or need to be, obtained from the Conservation Commission? Needs to be obtained Obtained , Date issued 10. Do any signs exist on the property? YES / NO IF YES: Describe the size, type and location: '-A' acY Vri, nr: \-eel ,'2)1�n Are there any proposed changes to, or additions of, signs intended for the property? YES l NO IF YES: Describe the size, type and location: e P \C L P 4,S0 \ C nec i \\orn, COh c\Q \ r-n th. Page 2 of 3 City of Northampton 1 ,X9-'114,2 :', .,4,: t Massachusetts L ' <<i 3 DEPARTMENT OF BUILDING INSPECTIONS fx -,- : ;. 212 Main Street • Municipal Building v ''' - Northampton, MA 01060 At e' INSPECTOR Application for a Permit to Place or Maintain a Sign Or other Advertising Device, or Marquee ��/39.7 (Application to be filled out in ink or typewritten) Number. Plans must be filed with the Building Inspector Erection ( ) before a permit will be granted. Alteration ( v ) Repair ( ) Repainting ( ) V c : Removal ( ) FEE PAGE PLOT 2 2010 OC1 ; Northampton, Mass. ...Q . • a "" 20.10 To the Building Commissioner: Application for a permit to,place or maintain a sign or other advertising device, or marquee. BUSINESS NAME ...t 'r 4 :1.-nel.\.... nc e, 1. Location, Street and No. ....AC.K.VO... .►.. ' e.t.a 2. Owner's name ....tier 4... Cr.,.onel\ n CGOCI~, 3. Owner's address ..Z2 0(. ,t ... C.e t\\us sopkx1.,.('f)A..o.ad.,$)0.. 4. Maker's name .... TX‘i...5 0 C (IC.. 5. Maker's address 1 .1.4� 5....30 rl.9.§,k1d,..C? ....C.1.I0.\ - 1Q56 6. Erector's name ....050::).\.t. 3 si -.)... `.n .0 • 7. Erector's address . a. X....t _5..?.C.1.() .• k. , (`(\t' ...(:).1.141:: ..I.C65 SIGN KIND OF SIGN (Designate) 1. Sign will be (check one) illuminated / Non-illumipated 2. Will sign obstruct a fire escape, window or door? ..g©.. Marquee 3. Lower edge will be ft ins above the public way. Projecting 4. Upper edge will be ft ins above the public way. Roof 5. Height ..!l.ft..Q.ins Width . .acft...ins Temporary 6. Face area .$ 0.sq. ft. Wall Y 7. Inner edge will be ins from the building or pole. Ground 8. Outer edge will be ins from the building or pole. Other 9. Face of building or pole is ins back from the street line. 10. Sign will project ins beyond the street line. 11. Sign will extend ft ins above the building or pole. 12. Of what material will sign be constructed? Frame Ci lom • Face. ..1Q 13. Estimated cost $...a... s; •:uc.).. The undersigned certifies that the above statements are true to the best of his knowledge and belief. (i nature o 9 Owner or Agent) Page 1 of 3 File # BP- 2011 -0307 APPLICANT /CONTACT PERSON AGNOLI SIGN CO INC ADDRESS/PHONE P O BOX 1055 SPRINGFIELD (413) 732 -5111 PROPERTY LOCATION 8 NORTH KING ST MAP 18D PARCEL 028 001 ZONE HB(100) //WP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 77 �� D Fee Paid Typeof Construction: REPLACE ILLUM SIDE WALL SIGN - WEBBER & GRINNELL INSURANCE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: V 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 11(' 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. City of Northampton i.Kt 1815 Lot028 Zone HB(100) / /WP Massachusetts Date issued 11/8/2010 0:00:00 Inspector of Buildings Permit # BP -2011 -0397 Permit Fee$30.00 SIGN PERMIT Business WEBBER & GRINNELL INSURANCE AddrAPVIVORTIT KING ST Applicant Installer AGNOLI SIGN CO INC Applicant Installer Address P 0 BOX 1055 Work Description REPLACE ILLUM SIDE WALL SIGN - WEBBER & GRINNELL INSURANCE Estimated Cost $2500.00 Building Department Approval by: 11. ALL INFORMATION MUST BE COMPLETED; PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION. 12. This column to be filled in by the Building Department. Existing Proposed Required by Zoning Lot Size Frontage Front: Setbacks: Side: L: R: L: R: Rear: Building Height Bldg Square Footage % Open Space: (Lot area minus bldg and Paved parking) # of Parking Spaces # of Loading Docks Fill: (volume & location) 13. Certification: I hereby certify that the information contained her is tru and accurate to the best of my knowledge. DATE: 11/ 1)) O APPLICANT'S SIGNATU NOTE: Issuance of a zoning permit does not relieve an ap• icant's burden to comply with all zoning Requirements and obtain all required permits from the Board of Health, Conservation Commission, Department of Public Works and other applicable permit granting authorities. FILE # Page 3 of 3 H THIS FORM IS PART OF THE SIGN PERMIT APPLICATION File No. ZONING PERMIT APPLICATION PLEASE TYPE OR PRINT ALL INFORMATION (-�C` 1. Name of Applicant: Y') C 6O C .) Id J Address: , V )( 1055 ,r (`n e 1 - Telephone: LI ) -1 51 2. Owner of Property: 11 Lah l -� r , ri lP Address: cA i\\ th Kim `) .\ . r Pen 1. CIaQO Telephone: A- 113 - - ( 3. Status of Applicant: Owner VContract Purchaser Lessee _Other(explain): 4. Job Location: ) IAN V ' S (1(t �� ee Parcel ID: Zoning Map # Parcel # District(s) (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Existing Use of Structure /Property: tt., t...* 6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary) \ f iThn Qc C)\o dr r Q \c.c P ,11, "m;cy\ -eA Cr.lp )CA( PC tZh,1-e ('c(\ \' kp ce Vh ttC:O )\(X CL� pr-c 7. Attached Plans: ✓Sketch Plan Site Plan Engineered /Surveyed Plans 8. Has a Special PermitNariance /Finding ever been issued for /on the site? NO ✓ DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: Enter. Book Page and /or Document # 9. Does the site contain a brook, body of water or wetlands? NO °✓ DON'T KNOW YES IF YES: Has a permit been, or need to be, obtained from the Conservation Commission? Needs to be obtained Obtained , Date issued 10. Do any signs exist on the property? YES ✓ NO IF YES: Describe the size, type and location: 1 4' CL' (. p1' (6' +0Cl`,-\ ( \10 MCK-1� �, �� 1Cl C( t1 )\\ • Are there any proposed changes to, or additions of, signs intended for the property? YES ✓ NO IF YES: Describe the size, type and location: ` eyek (AN-1l\ F. (7 T Oa Q, a An. eCA (" Qkg c>es `- \5() cho Page 2 of 3 „ r *' s, City of Northampton pr Massachusetts _ t---"Z, -4. � � j DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building +3 b ; � � Northampton, MA 01060 • �' 0' INSPECTOR Application for a Permit to Place or Maintain a Sign Or other Advertising Device, or Marquee Mpip.be (Application to be filled out in ink or typewritten) Number Plans must be filed with the Building Inspector Erection ( ) before a permit will be granted. Alteration ( ) Repair ( ) Repainting ( ) ”' Removal ( ) FEE ,, // PAGE PLOT Northampton, Mass. •NQi:Pfl1 k r / 51 " 201.0 To the Building Commissioner: Application for a permit to place or maintain a sign or other advertising device, or marquee. BUSINESS NAME .. ;.p�bo.e.c ...q...l:]ca.ocie 1. Location, Street and No. S...In,t. th.....I 3 e Q 2. Owner's name L3.ebber '4 t. : i xQ.11 3. Owner's address `IS .I 1 i.ns .. 5Nfe.QA - l . (. kbampc):..00 A...Q.lCtrz4:?.. 4. Maker's name ..... J OQ�►... , �8f).... Co 5. Maker's address .Po.. &15....111b6 tIoa ►I`id,...a1a...0 ?.I.l , 1 .:.1.4.6.5 6. Erector's name ...c). 0.0i% 3.60 ...C..0 V 7. Erector's address .. 1 . ,.e.` d, c,),...,,u. l - .t.o.5,5 SIGN KIND OF SIGN (Designate) 1. Sign will be (check one) illuminated ../... Non -illu inated 2. Will sign obstruct a fire escape, window or door? ..a... Marquee 3. Lower edge will be 4>. ft ins above the public way. Projecting 4. Upper edge will be ...4..ft ins above the public way. Roof 5. Height . .5..ft..4..ins Width .Ao..ft..a.ins Temporary 6. Face area ...sq. ft. Wall 7. Inner edge will be 5`..ins from the building or pole. Ground ,J 8. Outer edge will be `...ins from the building or pole. Other 9. Face of building or pole is cici..ins back from the street line. 10. Sign will project .(k ..ins beyond the street line. 11. Sign will extend .. ..ft ins above the building or pole. 12. Of what material will sign be constructed? Frame cilQrn • Face...le.unn 13. Estimated cost $...5.. a CO. ... The undersigned certifies that the above statements are e to the • est of his knowledge and belief. 7 / (Signature of Owner or Agen Page 1 of 3 File # BP- 2011 -0411 APPLICANT /CONTACT PERSON AGNOLI SIGN CO INC ADDRESS/PHONE P 0 BOX 1055 SPRINGFIELD (413) 732 -5111 PROPERTY LOCATION 8 NORTH KING ST MAP 18D PARCEL 028 001 ZONE HB(100) //WP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out C 6 36 Fee Paid Sf' � Typeof Construction: REPLACE ILLUM GROUND SIGN - WEBBER & GRINNELL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION PRESENTED: Ap proved 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 �- f /I/9 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. 1 City of Northampton Map 18D Lot028 Zone HB(100) / /WP Massachusetts Date issued 11/8/2010 0:00:00 Inspector of Buildings Permit # BP -2011 -0411 Permit Fee$30.00 SIGN PERMIT Business WEBBER & GRINNELL Ades 8 NORTH KING ST Applicant Installer AGNOLI SIGN CO INC Applicant Installer Address P 0 BOX 1055 Work Description REPLACE ILLUM GROUND SIGN - WEBBER & GRINNELL Estimated Cost $5200.00 Building Department Approval by: • • ..)outr. Supervisors Lie. No. 011878 Prefeival Tel. 413 - 584 -1367 YOUNG ?LOOPING CO4 Mao 413- 586 -9167 Fax 413- 585 -0226 P.O. BOX60066 FLORENCE MA 01062r0066 • Customer : Webber & Grinnell Insurance Date: 12/31/09 Address: 8 North King St. Northampton, MA. 01060 Yob Location Main roof and low roof. SPECIFICATIONS: 1. Remove all ballast stone on upper and lower roof areas. 2. Remove the existing membrane roofing and insulation down to the tar & gravel roof. 3. Apply 3.3 inch polyisocyanurate insulation over all roof areas. Aged R value 20,4 4. Install Carlisle's .045 gauge reinforced mechanically attached roofing system. Adhere the membrane to all parapet walls. 5. Flash all walls, edges, and roof penetrations with an approved Carlisle detail. 6. Fabricate and install .032 gage brown aluminum edge metal to the low roof area. 7. Remove all our roofing debris from the job site and dispose in legal landfill. 8. Obtain a building permit for the work. 9. Upon completion of work Carlisle will inspect the job an issue the owner a Fifteen (15) year Golden Seal Total System Warranty. As m l leywrerlaed ro be ao a ykd t *ereOOns adeviaton from above become a Invdr#g 9eve end will be hoacu[ad ony u ni s O con and w bemme 44 effiacaerpe over end Oa/Mho 01 *Omuta MI 440 010111 0004 upon $(41". aeekMta mdel0ye beyond 040000001. Owner b 044( Ora 4401 otlwr neceeaery 10 .400 1 08 . 0(14 peld W 1n O a0 deye ere e 4 M 00819a to 1 1$ % ee p r e rryry rnwoaannnt ,ona,eunp*Id01144010. a, 110 eventten101 0440(00Ia108104801mcdleci Authorized 10111 0.19r u,0 244 e m *Iea ..it/not V'eeet0pay se mete44044444 Signature Richard Yo President • Acceptance of Proposal -The above pricesdpveiftcatione £ I / / and conditions are satisfactory and are hereby accepted. You arc authorized signature ■ / ► . . _ to do the work as specified. Payment will be made as outlined above. . Acceptance Date of Acceptance 33 `/-ra0 Versionl.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 . 1, 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 (1 VC— 00 /C 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. Si ned underth s e Ities Print Name .._,.. -... _...,- Signature of Owner /Agent Date SECTION. 12. - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature 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 0 No i Yersion1.7 Commercial Building Permit May 15, 2000 • SECTION;' 9- P1ROFE$5IONAL.DESIGN AND CONSTRUCTION.SERVI = FOR:BUILDINGS AN D:STI�UCTURES.SUBJECT TO • CONSTRUCTION CONTL P ROURSUAT IN N TO'7e0;CR:116 MORE.XHAN "35,000 -C. )1OF'.ENCLOSED SPACE) • 9.1 Registered Architect: Not Applicable ❑ Name (Regletrent): I �� I Registration Number .. Address 4 I Expiration Dale Signature Telephone 9.2 Registered Professional Engineer(s): Neme Area of Responsibility • Address Registration Number I Signature Telephone Expiration Date • Name Area of Responsibility 1 1 1 Address Re . istration Number ( Signature Telephone Expiration Date Neme Area of Responsibility Address Registration Number 11 1 Signature Telephone Expiration Date 1 Name Area of Responsibility 1 Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ ( Company Name: Responsible In Charge of Construction • Address 1 • Signature Telephone • • • • Versionl.7 Commercial Building Permit May 15, 2000 Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size E 11 1 ( ^~ Frontage 1 �___�_- _ __ � 11 Setbacks Erna 1 1 [J J Side L :1 1_ R_J L:1 1 RI — 1 L 1 1 1 1 1 1 1 Building Height , 1 1 I [ 1 Bldg. Square Footage 1 -1 i —1 % EJ r 1 Open Space Footage �•--------��--�� (Lot area minus bldg & paved FJ LJ =3 �t Parking) # of Parking Spaces 1 1 1 --- Fill: l i (volume 8c Location) _ �J ' A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW • YES IF YES, date issued: 1 ----- IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW • YES 0 IF YES: enter Book 1 Pager + and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW • YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® - Obtained 0 , Date Issued: L C. Do any signs exist on the property? YES (• NO IF YES, describe size, type and location: C 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. WIII 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 ® NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 4 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: Se., f C � " � zC ` � 'I � % � � j � l.' ___ ___ —_ 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 ❑ A - 5 ❑ 1B ❑ B Business RI 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I 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: 1 M Mixed Use ❑ Specify: r w__mm___ - �� S Special Use ❑ Specify: - _ ___. COMPLETE THIS SECT1ON IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: 1 Proposed Use Group: 1_ ~ - 1 l Existing Hazard Index 780 CMR 34): L___ ._._.....�. , ____._., Proposed Hazard Index 780 CMR 34): l � .-._...._ � _^`._� SECTION 6 BUILDING HEIGHT AND AREA I • BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY T ,1 f. .j Floor Area per Floor (sf) °' 4. : 1 `� tat ._ � ",• ' od L. j 2� 3rd 3'd r___. ._......_._ --- .. L { 4th 4s' _...._._ Total Area (sf) I -_ *.] Total Proposed New Construction (sf Total Height (ft) ( 1 Total Height ft __ G 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Z,, to nformation: 7.3 Sewage Disposal "System: Public ID Private ❑ Zone �, Outside Flood Zone Municipal ❑ On site disposal system❑ * s' Version1.7 Commercial Buildin • Permit Ma 15,20r ��� City of Northampton i e- i e r !, Building Department ^ � v , Z12 Main Street I `', Room 100 �� , 1 4.• }'� 4J l "-- i l Northampton, MA 01060 ifx , r t -a <a ail '` + '� �. phone 413 - 587 -1240 Fax 413 - 587 -1272 t a,, tFa la APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE O - 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 (iU�';(j�j�2X (�ri /1 VI I � t vu hC C..- M a p . Lot Unit 101;e Overlay Di Iv(G r 4- n ( a ' '14 kvi , "/9 • D/D&t — • / - - _ . . , Elm St. District: :CBDistiict' SECTION 2 - PROPERTY :OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: _ _ __ Signature Telephone 2.2 Authorized Agent: i c,,j 1 6.t.v-d X - ...(i r.., a— go - [ fi.Prre-j'IFE, , :i Name (Print) Current Mailindress _ f // ' f _w..___ 11/3 Ad �S t 7 :- - - 9 --. _ - -- _ l // L '-l v Signature / z / Telephone W SECTION 3 - ESTIMATED C STRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only., completed by permit applicant . : ..:: 1. Building - UC vY . � M� 1 (a) Building Permit F. ee 2. Electrical — (b) Estimated Total Cost of - : Construc tion from(li) 3. Plumbing Building Permit Fee -------1 L.__ --- 4. Mechanical (HVAC) 5. Fire Protection . . 6. Total = (1 + 2 + 3 + 4 + 5) i - 1 `f t (0(X) (X% Check Number 00 • - This Section For Official Use Only Building Permit Number Date Issued: Signature:: Building Commissioner /Inspector of Buildings Date ,:. • • NOG ST BP- 2010 -0783 GIS #: COMMONWEALTH OF MASSACHUSETTS .liviap:Block: 18D - 028 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- 2010 -0783 Project # JS- 2010- 001170 Est. Cost: $44600.00 Fee: $267.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: YOUNG ROOFING CO INC 011878 Lot Size(sq. ft.): 47523.96 Owner: WEBBER RICHARD J & WILLIAM D GRINNELL TRUSTEES Zoning: HB(100) //WP Applicant: YOUNG ROOFING CO INC AT: 8 NORTH KING ST Applicant Address: Phone: Insurance: P O Box 60056 (413) 584 -1367 Workers Compensation FLORENCEMA01062 ISSUED ON :3/10/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL NEW ROOF 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 3/10/2010 0:00:00 $267.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo