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23B-015 (11)The Commonwealth of Massachusetts City of Northampton Certificate of Occupancy In accordance with 780 CMR, Section 120.0 (The Seventh Edition of the Massachusetts State Building Code) this Certificate of Occupancy is issued to the premise or structure or part thereof as herein identified. Identify Name of Building of Space Within Certificate No. Issued to On Call Urgent Care Center BP -2011-0676 Identify property address including street number, name, city or town and county Located at 6 Hatfield Street Northampton, Hampshire, Massachusetts Use Group Allowable Classification(s) Business Occupant Loads 1 occupant per 100 square feet (grossl This Certificate of Occupancy is hereby issued by the undersigned to certify that the premise, structure or portion thereof as herein specified has been inspected for general fire and life safety features. This certificate shall allow for the use as herein described and in conformance with any and all conditions as identified below. It shall be posted in a conspicuous place within the space as directed by the undersigned. Failure to post the certificate, failure to comply with conditions or, tampering with the contents of the certificate is strictly prohibited. Conditions of Use Structural and Safety systems must be maintained. Name of Municipal Charles Miller Date of Final Map/Plot: BuildingOfficial Inspection 03/30/11 Signature of Municipal Date of G 23B -U15 Building Official��6 Issuance 03/30/11 CERTIFICATE OF LIABILITY INSURANCE OP ID SF �..� TRIPS51 DATE(MMIDD/YYYY) 1 02/03/11 PRODUCER IRM Insurance Agency, Inc. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Barry M. Stephens, CPCU HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 75 North Main St. -P 0 Box 564 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. East Longmeadow MA 01028 DATE MWDD ATIN Phone: 413-759-0010 Fax: 413-759-0017 INSURERS AFFORDING COVERAGE NAIC # INSURED Triple S Construstion LLP & or Triple S Sunroom Inc. dba INSURERA: Peerless Insurance INSURER B: Betterliving Patio & Sunrooms of the Pioneer Valley Reality LLC 2345 Boston Road Wilbraham MA 01095 INSURER C: 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD DATE MWDD ATIN LIWTS AUTHORIZED REPRESENTATIVE GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A X COMMERCIAL GENERAL LIABILITY CCP9843121 04/13/10 04/13/11 PREMISES (Ea occurence) $ 50000 CLAIMS MADE [i(] OCCUR MED EXP (Any one person) $ 15000 PERSONAL &ADV INJURY $ 1000000 X GL Extn Endo Appl GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMPIOPAGG $ 2000000 X POLICY PRO 71 LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000000 A ANY AUTO BA9842917 04/13/10 04/13/11 (Ea accident) BODILY INJURY $ ALL OWNED AUTOS X SCHEDULED AUTOS (Per person) BODILY INJURY $ X HIRED AUTOS X NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - FA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ 5000000 A X OCCUR CLAIMS MADE CU9843521 04/13/10 04/13/11 AGGREGATE $ 5000000 $ DEDUCTIBLE $ X RETENTION $ 10000 WORKERS COMPENSATION QTH- X TORY LIMITS ER AND EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 500000 A ANY PROPRIETOR/PARTNER/EXECUTIV �YIN WC8579575 01/02/11 01/02/12 OFFICERIMEMBER EXCLUDED? iyi (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 500000 If Yyes, describe under SPECIALPROVISIONS below E. L. DISEASE -POLICY LIMIT $500000 OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ACORD 25 (2009/01) ©1933-2009 ACORD CORPORATION. AH ngnts reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION PR00007 DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR For Proof Of Insurance Only REPRESENTATIVES. AUTHORIZED REPRESENTATIVE IRM Insurance Agency Inc. ACORD 25 (2009/01) ©1933-2009 ACORD CORPORATION. AH ngnts reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street - Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name (Business/Organization/Individual): 7;elplc —:1, Address: 231L�_ Em 774 ,xJ !'e, City/State/Zip: /Z -A6 A5:tZ4, AM elerf_ Phone.#:�- Are you an employer? Check the appropriate box: to I am a employer with*1�_' � 4. I am a general contractor and I 0. employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance required.] comp. insurance.$ 5. EJ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp, right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no, employees. [No workers' comp. insurance required] Type of project (required):.' 6. ❑ New construction 7. remodeling 8. ❑ Demolition 9. (] Building addition 10.❑ Electrical repairs or additions 1 LE] Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors 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: F&Z-V_Les ! C:01 — Policy # or Self -ins. Lic. #: V IC, A;'517 q'S 7-L Expiration Date: j 2 /-,r Job Site Address: f%izl%//fin/, City/State/Zip: 0,rl_ �/� C910�, e1 Attach a copy of the workers' compensation,`pollcy 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investieations of the DIA for insurance coveraee verification. I do hereby certcf under the pains and penalties of perjury that the information provided above is true'and correct Phone #:. Z11 use only. Do not write to this area, or town official. City or Town: Permit/License #. Issuing Authority (circle one):. 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6i Other Contact Person: Phone SlnartZone Communications Center. SmartZone Communications Center Page 1 of 2 t image001.jp9 wall signs.jp9 littr)://sz0099.wc.maii.cotncast.net/h/viewimaLes?id=436800 1/4/2011 ..1� �' Cerctemen Ly Call Urgent Cere Centad: MocDenalA Lynn F. Ilk Name: On Cnkv` Can Dobv: L--111 K.P Ci t•fVy Tl'usdy, D.,30, 7010 littr)://sz0099.wc.maii.cotncast.net/h/viewimaLes?id=436800 1/4/2011 ..1� �' Cerctemen Ly Call Urgent Cere Centad: MocDenalA Lynn Ilk Name: On Cnkv` Can Dobv: L--111 K.P Ci t•fVy Tl'usdy, D.,30, 7010 n, —1 tA-I halo: .': 7010 SVry i. I r+r:t•nlry Inr, In<_..41 Ilfll.l� I nr wlvnrl. pole sign.jpg littr)://sz0099.wc.maii.cotncast.net/h/viewimaLes?id=436800 1/4/2011 Version1.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes Q No SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, l) or , C�(1 p f1- t I as Owner of the subject property hereby authorize Y 0 e �c Yu$ t -h to act on ehalf, in all matters relati work authorized by this building permit application. Signature of Owner Date ti I, �Wi l� Cil iNl � 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 penalti of perjury. 0 i e' 1 Ility-1 Print Name , c� 1 Signature of Owner/Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ �' /)• - 5 ; G V Name of License Holder : / 4 S -� License Number 7„4'/PC € S �c AJ$7__A?dc 774 AJ L L P -PA Address ° Expiration Date 4- 1D//_ 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 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: "I, _7� Name (Registrant : Address Signature �� 7 Telephone Not Applicable ❑ Registration Number /� 661 Expiration Date 9.2 Registered Arofessional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Signature Telephone Registration Number Expiration Date Name Area of Responsibility Address Signature Telephone Registration Number Expiration Date Name Area of Responsibility Address Signature Telephone Registration Number Expiration Date 9.3 General Contractor Tf"-zP Ly �� CJrl'J iALj4 T -,z v ry cJ L L-1PNot Applicable ❑ Company Name: ''T qo t -yl A S Responsible In Charge of Construction , ,3 4/ IS OS 7-6) iv tti D , L.�r�-KS R,9 /t4l�-7 In r4 : C ( o S - Address cell 1413 ` ;k46- vA9 (b S- Signature Telephone Version 1.7 Commercial Buildini2 Permit Mav 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 Rear L: R: L: R: Building Height Bldg. Square Footage % Open Space Footage (Lot area minus bldg & paved parking) % # of Parking Spaces Fill: (volume & Location) X A. 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 ® DON'T KNOW © YES IF YES: enter Book Page and/or Document # B. 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: �l C. Do any signs exist on the property? YES ® NO. IF YES, describe size, type and location: 1nJ PULA to poti}' tk;i; 16TZ5 bV ttdih� V D. Are there any proposed changes to or addition of signs intended or the property ? YES NO IF YES, describe size, type and location: 11� yk E. Will the construction activity disturb (clearading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NOing, gr G.- IF YES, then a Northampton Storm Water Management Permit from the DPW is required. , , � 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 19Existing Wall Signs ❑Demolition❑ Repairs ❑ Additions ❑ Accessory Building k' Exterior Alteration ElExisting Ground Sign a New Signs ❑ Roofing [I Change of Use ❑ Other ❑ Brief Description Enter a brief description here. e— Of Proposed Work: �' i ► ►� SECTION 5 - USE GROUP AND CONSTRUCTION TYPE SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING I PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (so 1 15t �25t 2nd 4/M 2nd A/, /Q 3rd3rd A)! /f /� 4th �l)q 4th �! Total Area (so I Total Proposed New Construction (so )� (Total Height (ft) I( Total Height ft 7. Wat r upply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public Private rl Zone Outside Flood Zone[] I Municipal ❑ On site disposal system USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-4 ❑ A-2 ❑ A-5 ❑ A-3 ❑ 1A 1B ❑ ❑ B Business " F-1 ❑ F-2 ❑ 2A 2B 2C ❑ I ❑ ❑ E Educational ❑ F Factory ❑ H High Hazard ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3A 3B ❑ ❑ I Institutional ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ S-1 ❑ R-2 ❑ S-2 ❑ R-3 ❑ 5A 5B ❑ ❑ S Storage ❑ U Utility ❑ Specify: Specify: M Mixed Use ❑ S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE Existing Use Group: 11 / A.) E -o `- /xtC Existing Hazard Index 780 CMR 34): / Proposed Use Group: Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING I PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (so 1 15t �25t 2nd 4/M 2nd A/, /Q 3rd3rd A)! /f /� 4th �l)q 4th �! Total Area (so I Total Proposed New Construction (so )� (Total Height (ft) I( Total Height ft 7. Wat r upply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public Private rl Zone Outside Flood Zone[] I Municipal ❑ On site disposal system Versionl .7 Commercial Building Permit Mav 15.2000 SECTION 1 - SITE INFORMATION Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit - 212 Main Street Sewer/Septic Availability lJ., 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 1.1 Property Address: This section to be completed by office (pry +1"- � 'Co j S� Map Lot Unit N Oyl k(A + r i v, fA A U 1 O L'' D Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name Current Mailing Address: (Print)I _ L &+hQ� 5 L �� Signature Telephone 2.2 Authorized Agent: `\ �l ` � F� �/ Name (Print) / /� Current Mailing Address: C Y •4'-a yV' tp-A VVIYA 0100 Signature TelephoneI�'�{-� X3C`{ �3-Ta2C'�Z SECTION 3 - ESTIMAT CO STRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ---7 Gee f7, i- (a) Building Permit Fee 2. Electrical g nOC), d:0 (b) Estimated Total Cost of Construction from 6 3. Plumbing c� J C' ZS c o Building Permit Fee 4. Mechanical (HVAC) i I0L ©, 00 5. Fire Protection 6. Total = 0 +2+3+4+5) G N S-(i�> Check Number /� - D This Section For Official Use Only Building Permit Number Date Issued Signature: Date Building Commissioner/Inspector of Buildings File # BP -2011-0676 APPLICANT/CONTACT PERSON TRIPLE S CONSTRUCTION CO LLP ADDRESS/PHONE 2345 BOSTON RD WILBRAHAM (413) 596-8262 PROPERTY LOCATION 6 HATFIELD ST MAP 23B PARCEL 015 001 ZONE SI(100)// THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INTERIOR RENOVATIONS (FOYER & 2 BATHROOMS) 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 INFO ATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Major Project: Site Plan AND/OR ZONING BOARD PERMIT REQUIRED UNDER: Finding Special Permit Special Permit With Site Plan Special Permit With Site Plan Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Septic Approval Board of Health Water Availability Sewer Availability Permit from Conservation Commission Well Water Potability Board of Health Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay --/I- - // �- I 2 -JI 0 l Signa re of Building f cia 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. • - r 6 HATFIELD' BP -2011-0676 GIS #: _ COMMONWEALTH OF MASSACHUSETTS Ma :Block: 2 - 015 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: 3uilding DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)' Category: ren, on BUILDING PERMIT Permit # 3P-2011-0676 Project # JS -2011-001103 Est. Cost: $4( .00 Fee: $281.40 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin TRIPLE S CONSTRUCTION CO LLP Lot Size(sq. r: 31319.64 Owner: SIX HATFIELD ASSOCIATES Zoning: Sl(V Applicant. TRIPLE S CONSTRUCTION CO LLP AT. 6 HATFIELD ST Applicant; gess: Phone: Insurance: 2345 BOSIy RD (413) 596-8262 WILBRAH,' 11MA01095 ISSUED ON.2/11/2011 0.00:00 TO PE ' -9RM THE FOLLOWING WORK:INTERIOR RENOVATIONS (FOYER & 2 BATHRO( ;) POST Til' ':ARD SO IT IS VISIBLE FROM THE STREET Inspector of ,bing Inspector of Wiring D.P.W. Building Inspector Undergroun;, Service: Meter: Rough: Rough: House # Driveway Final: Final: Final: Gas: Fire Department Rough: Oil: Final: Smoke: Footings: Foundation: Rough Frame: Fireplace/Chimney: Insulation: Final: THIS PE l ''r MAYBE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF] :ULES AND REGULATIONS. Certificate Occupancy Signature: FeeType: Date Paid: Amount: Building 2/11/20110:00:00 $281.40 212 Main Street, Phone (413) 587-1240, Fax: (413) 587-1272 Louis Hasbrouck — Building Commissioner