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25A-108 From:413 447 1977 07/02/2010 12,54 #369 P.001/002 AICQR' DATE IMINODNYYY1 �.,.. - CERTIFICATE OF LIABILITY INSURA N CE 7/22018 PRODUCER (413) 935 -1200 PAX: (423) 567 -5300 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THUS CERTIFICA1Tc DOES NOT AMEND, EXTEND OR Berkshire Insurance Group, Inc. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 138 Longmeadow St. Longmeadow MA 01106 INSURERS AFFORDING COVERAGE NAIC # INSURED _ INSURERA Bartfo d G�A19TtEl.lty Insurance 29424 INSURER a; Safety Insurance Coanpany 39454 Charista Construction Services, Inc . INSURER C: Savers Property & Casualty - 38 Harkness Avenue N tLSURERD: �"`-_ � - - ]East Lo YIA 01028 -----_ .__.._._.._-- INSURER e: - COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUC1' 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. T''' , - � POLICY POUCY EXPIRA • N �- RA I �af _� � ::.. POLICYIAAIBER PO ,. t 1,� . - ■.444 ,. EFFECTIVE PO 1 ;„, a.��414 UMfB _,_.._. _ _ _GENERAL LIABIWTY EA.HOCCURRENCE $ 1,000,000 15A MO TO RENTED _X COMMERCIAL GENERAL LIABILITY pMWg606P AIDNNN , $ 300 A . 1CI.AIMS MADE rXI occUR WIRMIVIT0093 5/6/2010 5/6/2011 ME3 EXP (Any one person) 5 10,000_ - _ . PERSONAL B M N INJURY S - � 7 F OOD, 000„ _, ___ _ GE1tERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER; PRUDUCTS - COMP/OP AGG $ 2,000,000 '- 1 1 POLICY 1 [1 71 i ri we W _ AUTOMOBILE LIABILITY COMBINED SINGLE llMfr $ _ ANY auto (Fa aeoidant) _— E ALI. OWNED 5021567 6/2/2010 6/2/2011 BODILY 6 250,000 X SCHEDULED AUTOS (Pe1 person) , - -._, _ __ X HIRED AUTOS BODILY INJURY $ 800,000 X NON -OWNED AUTOS (Pat .acclasnt) -_ PROPERTY DAMAGE $ 100,000 (Per accident) GARAGELMIBILITY AUTO ONLY. M ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ - - - -- y AUTO ONLY: AOC S (EXCESS / UMEIRELAA LIABILITY EACH OCCURRENCE S 1 1 OCCUR [11 G CLAIMS MADE AG PEGATE $ - _._ _ 9 DEDUCTIBLE --�� F 5 RETENTION $ _ - $ f WORUER8COMPENSAroN ,�( VVC STATU 0TH- . AND EMPLOYERS' UABILJTY Y! N J1 l:.8..., ��.. - .. ANY PROPRIETOR/PARTNER/EXECUTIVE � E.L. EACH ACCIDENT 5 1, 000 OFFICER/MEMBER EXCLUDED? Fit t (Mandatory In NH) IPC0002537 6/8/2010 6/8/2011 E.L orSEASE - EAEIr1PLOYEE S 1,000,000 If yea describe under - 8PECIAt, PROVISIONS below E.L. O111EASE - POLICY LIMIT $ 1,000,000 OTHER --I — DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSE/JENT f SPECIAL PROVISIONS Proof of Coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTNEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 , DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED'F0 THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LABILITY OF AN1' KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. .� AUTHORIZED REPRESENTATNE _ Judi Mabee /J0 ( ". " - ` -- ACORD 25 (2009(01) ©1888 -2009 ACORD CORPORATION- AO rights reserved. INS025 (zoaso,) The ACORD name and logo are registered marks of ACORD :_" The Commonwealth of Massachusetts Department of Industrial Accidents r _ Office of Investigations `. ; 600 Washin Street Boston, MA 02111 _ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers Applicant Information Please Print Legibly , Name (Bus C -Le (1 * S -� C L t, . 4 t\ c _ Address: ? `4{c Ax Sc .k Lx....sz City /State /Zip:Ece4 tc LIw4,-0P,..,� U' LCD 14 Phone #: I ll JS - () 5'r Are you an employer? Check the appropriate box: Type of project (required): I am a employer with Li 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. ID 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 g. ❑ Demolition working for me in any capacity. employees and have workers' 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 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 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. 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 t- ( S A, C� � W - goCkt 1 , � Policy # or Self -ins. Lic. #: C 0 co a5-S -7 Expiration Date: - - )0 ( I ` Job Site Address: 351 Vi e Sit- City /State /Zip: V Cb rL ' c, ikA. 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 5250.00 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 hereb ertify under th ains , nd , • ► e ie F ury that the information provided above is true and correct. i, `� Signature: Date: `�) C Phone #: l it ? — c — Official use only. Du nut 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 #: • 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 0 No Bc SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT , as Owner of the subject property hereby authorize act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I , 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. Pri t Name Q_ Sign re of Owner/Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder ? L License Number Number (.! dress ()Q kL*A..9 Expiration Date ,L Si ature Telephone SECTION 13 -WORKERS COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Wcrkers 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 jgr No 0 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: L 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 C 1 1 oot c Not Applicable ❑ Company Name: .._ Responsible In Charge of Construction A. dress iAL X13 �� „ f 7s'" Sig ? ure Telephone Version1.7 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 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 Q DONT KNOW YES (3 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 110, YES IF YES: enter Book Page and /or Document #' B. Does the site contain a brook, body of water or wetlands? NO 0 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: C. Do any signs exist on the property? YES 0 NO r°i11 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 er 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 4, IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ' 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 ❑ RepairsSI Additions ❑ Accessory Building ❑ Exterior Alteration ah existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description Enter a brief description here. r-/Z tu-e «t L'i'e,--1/4" d ,''Y''""t 4 Lam" s v t �. r ‘-. "'-r,. Z- i Lc A-eC -•e.1, c�..Q1LtkAy 4 c..,-4,(4 • lZ�u ti z b,- ...,0".1/1. �r � H t �.�c a �� • Of Proposed Work: C 7 Q 4'r7L` ., . fir S oLki t 65- c ) s r y c v c. SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly Cl A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ A -4 0 A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ , 2B - I ' ❑ F Factory ❑ F -1 0 F -2 0 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: r _ _, „ W, _ �,_.. �.,_�..._ _ ._ r.... _ _ ..- - _. _., 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):, „.._ ,_w _.,. __ . SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) 1s 1s 2nd .,.. ._ .. .. ..... .... ......... 2 nd 3rd _ _ _._ __ 3r .. 4 th 4 Total Area (sf) Total Proposed New Construction ,(sf) Total Height (ft) ...,,.,...,_ _ .. ,......., _...,...,,..M. Total Height ft ... ,... 7. Water S ply (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 P Version 1.7 Commercial Building Permit May 15, 2000 Departmen use oil City of Northampton S ta t us of P ; ` , , Building Department Curb CDnv 212 Main Street Sewer /SepticAvaiIability / . Room 100 Water/WWII Ava lal _: t> " ) Northampton, MA 01060 Two Sets of Structural Plans phone 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans R - "'" r t PECTI Other specify �" ( s*1* 01060 " 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 '3 i Pi- . ? c Map Lot Unit Zone Overlay District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of R cord: M / _. ,. Name (Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent: 23 , f e h . N VO in.vl Y . ' ? t r kcv cS S A t. ,,e G 1 k.c,. C'1 t ( 01, p Name (Print) Current Mailing Address l S Sit 5 1 7 .... . Signature �"'C ,' r Telephone 1 SECTION 3 - ESTIMATED CONSTRUC ION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit 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 - (1 + 2 + 3 + 4 + 5) Check Number 076 This Section, For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date CA L ta f z. (b L1' File # BP- 2011 -0059 r S JA ht. Fof CON APPLICANT /CONTACT PERSON JOSEPH KENNEDY 1 ,- •ro coM, ADDRESS/PHONE 38 HARKNESS AVE EAST LONGMEADOW (413) 525 -1735 D, . r N 3 1 BRI oir'73h tv ea 1)6 et „ at- LOCATION 5 BRIDGE ST MAP 25A PARCEL 108 001 ZONE SC(83)/URB(17)/ RC WO t!J Eft, N f.-0 THIS SECTION FOR OFFICIAL USE ONLY: Slivtrelai l ce AS PQ3si &E PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid /o2 u Typeof Construction: DRYWALL & INSULATE 1ST FLR KITCHEN & LOWER APARTMENT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 055440 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 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.